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'General Quarters'
Page 13
- Winter Clinical Conference
January 27-23
Volume 79 Number 1
January 1983
TRY AIR FORCE
*A
Experience Air Force medicine. It can be just what you’
like your medical practice to be. More time to practice medi-
cine. More time with your family. Even more time for your
hobbies. It’s all part of Air Force EXPERIENCE. Talk to a
member of our medical placement team today. Find out how
you can experience the perfect medical practice as an AIR
FORCE PHYSICIAN.
AIR FORCE
For further information call collect:
Richmond (804) 771-2127
Charlottesville (804) 971-8092
Roanoke (703) 982-4612
Norfolk (804) 441-6412
The West Virginia Tledical Journal
Official Publication of the West Virginia State Medical Association
POST OFFICE BOX 1031 . CHARLESTON, W. VA. 25324
Telephone (304) 346-0551
© 1983, West Virginia State Medical Association
EDITOR
Stephen D. Ward, M. D. (1984)
Wheeling
MANAGING EDITOR AND
BUSINESS MANAGER
Mr. Charles R. Lewis
Charleston
EXECUTIVE ASSISTANT
Mr. Custer B. Holliday
Charleston
ASSOCIATE EDITORS
David Z. Morgan, M. D. (1983)
Morgantown
John M. Hartman, M. D. (1985)
Charleston
Vernon E. Duckwall, M. D. (1986)
Elkins
Thomas J. Holbrook, M. D. (1987)
Huntington
L. Walter Fix, M. D. (1988)
Martinsburg
Joe N. Jarrett, M. D. (1989)
Oak Hill
Published monthly by the West
Virginia State Medical Association
under the direction of the Publica-
tion Committee. Original articles are
accepted on condition that they are
contributed solely to The Journal.
Postmaster send form 3579 to
The West Virginia Medical Journal,
P. O. Box 1031, Charleston, WV
25324.
Entered as second-class matter
January 1, 1926, at the post office
at Charleston, West Virginia, under
the act of March 3, 1879.
Subscription Rates: $10 a year in
the U.S.A.; $15 in foreign countries;
$2 per single copy. Advertising rates
furnished on request. Address all
communications to Business Manager,
The West Virginia Medical Journal,
Box 1031, Charleston, West Virginia
25324. Phone 346-0551.
Microfilm editions beginning with
the 1972 volume are available from
University Microfilms, Inc., 300 N.
Zeeb Road, Ann Arbor, Michigan
48106.
MEMBER, WEST VIRGINIA
PRESS ASSOCIATION, 1983
USPS 676 740
ISSN 0043 - 3284
CONTENTS
Scientific Articles
Metastatic Cancer of Unknown Origin: Ohio Valley
Medical Center Experience — Gurijala N. Reddy,
M. D. 23
Epikeratophakia: A New Treatment For Corneal
Irregularity and Keratoconus — Theodore P.
Werblin, M. D„ Ph.D. 26
Tension Pneumothorax During Anesthesia — Stephen
T. Pyles, M. D.; David A. Haught, M. D.; Elmer T.
Vega, M. D.; and Eduardo A. Rivas, M. D. 29
Scientific Department
Medical Grand Rounds From the West Virginia Uni-
versity Medical Center (Relapsing Polychon-
dritis)— Edited by Irma H. Ullrich, M. D. 32
The President’s Page
Our Legislative Program — Harry Shannon, M. D.:
President, W. Va. State Medical Association 40
Editorials
Priority Goof 41
Clark Kendall Sleeth, 1913-1982 41
Gold Rush 42
General News
Annual Meeting Program Taking Shape
AMA-FTC Dispute In Congress In Deadlock
Family Physicians Meet In April
WVU Hospital Post Filled
Continuing Education Activities
New WVU Dean Said 'Outstanding’
Special Departments
WVU Medical Center News x
Third-Party News, Views, Program Concerns xii
Obituaries xiv
County Societies xviii
Classified Section xxiii
Index To Advertisers xxiv
43
43
44
45
46
47
February, 1983, Vol. 79, No. 2
iii
UNIQUE
nr
j hat’s what each of
i | our patient’s needs
are. And we have
the medical and professional
staff to meet these needs.
In 1980, Saint Albans
Psychiatric Hospital opened a
$7.8 million building with 162
beds and expanded clinical
facilities. The hospital is fully
accredited by the Joint Com-
mission on the Accreditation
of Hospitals.
In addition to our general
psychiatric services, we offer
specific programs for alcohol-
ics and substance abusers,
children/adolescents, and
older adults.
Saint Albans, the only
private, not-for-profit psychia-
tric hospital in Virginia, has
served southwestern Virginia
since 1916.
When you have a patient
who needs the specialized ser-
vices of a psychiatric hospital,
call Saint Albans. Admission
can be arranged 24 hours a
day by calling 703 639-2481.
ctive Medical Staff:
Rolfe B. Finn, M.D., Medical Director
William D. Keck, M.D.
Morgan E. Scott, M.D.
Don L. Weston, M.D.
Davis G. Garrett, M.D.
D. Wilfred Abse, M.D.
Hal G. Gillespie, M.D.
Basil E. Roebuck, M.D.
O. LeRoyce Royal, M.D.
A
Saint Albans
Rsychratric Hospital
P. o. Box 3608
Radford, Virginia 24143
Saint Albans Psychiatric Hospital is approved for Blue Cross,
Cham pus, Medicare, and most major insurance companies.
For a free brochure, write Robert L. Terrell, Jr., administra-
tor, P. O. Box 3608, Radford, Virginia 24143.
The West Virginia radical Journal
Official Publication of the West Virginia State Medical Association
POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324
Telephone (304) 346-0551
© 1983, West Virginia State Medical Association
EDITOR
Stephen D. Ward, M. D. (1984)
Wheeling
MANAGING EDITOR AND
BUSINESS MANAGER
Mr. Charles R. Lewis
Charleston
EXECUTIVE ASSISTANT
Mr. Custer B. Holliday
Charleston
ASSOCIATE EDITORS
David Z. Morgan, M. D. (1983)
Morgantown
John M. Hartman, M. D. (1985)
Charleston
Vernon E. Duckwall, M. D. (1986)
Elkins
Thomas J. Holbrook, M. D. (1987)
Huntington
L. Walter Fix, M. D. (1988)
Martinsburg
Joe N. Jarrett, M. D. (1989)
Oak Hill
Published monthly by the West
Virginia State Medical Association
under the direction of the Publica-
tion Committee. Original articles are
accepted on condition that they are
contributed solely to The Journal.
Postmaster send form 3579 to
The West Virginia Medical Journal,
P. O. Box 1031, Charleston, WV
25324.
Entered as second-class matter
January 1, 1926, at the post office
at Charleston, West Virginia, under
the act of March 3, 1879.
Subscription Rates: $10 a year in
the U.S.A.; $15 in foreign countries;
$2 per single copy. Advertising rates
furnished on request. Address all
communications to Business Manager,
The West Virginia Medical Journal,
Box 1031, Charleston, West Virginia
25324. Phone 346-0551.
Microfilm editions beginning with
the 1972 volume are available from
University Microfilms, Inc., 300 N.
Zeeb Road, Ann Arbor, Michigan
48106.
MEMBER, WEST VIRGINIA
PRESS ASSOCIATION, 1983
USPS 676 740
ISSN 0043 - 3284
CONTENTS
Scientific Articles
Acquired Factor VIII Inhibitor (A Case Report) —
Susan Irby, M. D.: John S. Rogers II. M. D.; and
Douglas C. Wolf, M. D. 49
Early Attenuation Of Toxic Shock Syndrome With
Intravenous Nafcillin Sodium — Thomas T. Smir-
niotopoulos, M. D.; and Vettivelu Maheswaran, M. D. 52
The President’s Page
This One’s For You — Harry Shannon, M. D„ President,
W. Va. Medical Association 56
Editorials
Rigorous Standards 57
Save Now, Pay Later? 57
On The Artificial Heart 58
More On The Artificial Heart 58
General News
AMA President Annual Meeting Speaker 59
Programs On Infection Control, Tumors 60
16 Papers For April AAFP Meeting 62
WVU Geriatric Program March 16 63
Continuing Medical Education Activities 63
Review A Book 64
Winter Meeting Of Council 65
An Open Letter 66
AAFP Starts Memorial For Doctor Sleeth 67
Special Departments
WVU Medical Center News xvi
Third-Party News, Views, Program Concerns xviii
County Societies xxii
Book Review xxiii
Classified Section xxix
Index To Advertisers xxx
March, 1983, Vol. 79, No. 3
Candidates for
nutritional therapy...
10 , 000,000
alcoholics. Ethanol may
produce many effects that
together bring about nutritional
deficiencies, so that alcoholism
affects nutrition at many levels . 1
25,500,000 geriatric
patients. The older patient
may have some disorder or socio-
economic problem that can
undermine good nutrition . 2
23,500,000 surgical
patients. Nutritional status
can be compromised by the
trauma of surgery; and some
operations interfere with the
ingestion, digestion and absorp-
tion of food . 3
Indications: Prophylactic or therapeutic
nutritional supplementation in physio-
logically stressful conditions, including
conditions causing depletion, or reduced
absorption or bioavailability of essential
vitamins and minerals; certain conditions
resulting from severe B-vitamin or ascor-
bic acid deficiency; or conditions resulting
in increased needs for essential vitamins
and minerals.
Contraindications: Hypersensitivity to
any component.
Warnings: Not for pernicious anemia or
other megaloblastic anemias where vita-
min Bii is deficient. Neurologic involve-
ment may develop or progress, despite
temporary remission of anemia, in patients
with vitamin B ]2 deficiency who receive
supplemental folic acid and who arc inade-
Before prescribing, please consult com-
plete product information, a summary of
which follows:
Each Berocca® Plus tablet contains 5000 IU
vitamin A (as vitamin A acetate), 30 IU
vitamin E (as d/-alpha tocophcryl acetate),
500 mg vitamin C (ascorbic acid), 20 mg
vitamin B, (as thiamine mononitrate),
20 mg vitamin B 2 (riboflavin), 100 mg
niacin (as niacinamide), 25 mg vitamin B„
(as pyridoxine IICl), 0.15 mg biotin, 25 mg
pantothenic acid (as calcium pantothe-
nate), 0.8 mg folic acid, 50 meg vitamin B, 2
(cyanocobalamin), 27 mg iron (as ferrous
fumaratc), 0.1 mg chromium (as chromium
nitrate), 50 mg magnesium (as magnesium
oxide), 5 mg manganese (as manganese
dioxide), 3 mg copper (as cupric oxide),
22.5 mg zinc (as zinc oxide).
quately treated with B, 2 .
Precautions: General: Certain conditions
may require additional nutritional supple-
mentation During pregnancy, supplemen-
tation with vitamin D and calcium may be
required. Not intended for treatment of
severe specific deficiencies. Information
for the Patient: Toxic reactions have been
reported with injudicious use of certain
vitamins and minerals. Urge patients to
follow specific dosage instructions. Keep
out of reach of children. Drug and Treat-
ment Interactions: As little as 5 mg pyri-
doxine daily can decrease the efficacy of
lcvodopa in the treatment of parkinson-
ism. Not recommended for patients
undergoing such therapy.
Adverse Reactions: Adverse reactions have
been reported with specific vitamins and
The Vest Virginia Medical Journal
Official Publication of the West Virginia State Medical Association
POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324
Telephone (304) 346-0551
© 1983, West Virginia State Medical Association
EDITOR
Stephen D. Ward, M. D. (1984)
Wheeling
MANAGING EDITOR AND
BUSINESS MANAGER
Mr. Charles R. Lewis
Charleston
EXECUTIVE ASSISTANT
Mr. Custer B. Holliday
Charleston
ASSOCIATE EDITORS
David Z. Morgan, M. D. (1983)
Morgantown
John M. Hartman, M. D. (1985)
Charleston
Vernon E. Duckwall, M. D. (1986)
Elkins
Thomas J. Holbrook, M. D. (1987)
Huntington
L. Walter Fix, M. D. (1988)
Martinsburg
Joe N. Jarrett, M. D. (1989)
Oak Hill
CONTENTS
Scientific Articles
Pain and Its Pharmacologic Manipulation — Charles
D. Ponte, R.Ph., Pharm.D. 69
Emergency Thyroidectomy For Tracheal Obstruc-
tion — Romeo Y. Lim, M. D. 75
Scientific Department
Medical Grand Rounds From The West Virginia Uni-
versity Medical Center iThe Noninvasive Diag-
nosis of Coronary Artery Disease) — Edited by
Irma H. Ullrich, M. D. 78
The President's Page
Ethics, Medicine and Society — Harry Shannon, M. D.,
President, W. Va. State Medical Association 84
Published monthly by the West
Virginia State Medical Association
under the direction of the Publica-
tion Committee. Original articles are
accepted on condition that they are
contributed solely to The Journal.
Postmaster send form 3579 to
The West Virginia Medical Journal,
P. O. Box 1031, Charleston, WV
25324.
Entered as second-class matter
January 1, 1926, at the post office
at Charleston, West Virginia, under
the act of March 3, 1879.
Subscription Rates: $10 a year in
the U.S.A.; $15 in foreign countries;
$2 per single copy. Advertising rates
furnished on request. Address all
communications to Business Manager,
The West Virginia Medical Journal,
Box 1031, Charleston, West Virginia
25324. Phone 346-0551.
Microfilm editions beginning with
the 1972 volume are available from
University Microfilms, Inc., 300 N.
Zeeb Road, Ann Arbor, Michigan
48106.
MEMBER, WEST VIRGINIA
PRESS ASSOCIATION, 1983
USPS 676 740
ISSN 0043 • 3284
Editorials
Public Relations 85
DRGs 85
General News
116th Annual Meeting 87
Legislature Okays Hospital, Other Bills 88
Continuing Education Activities 89
Review A Book 90
Act Freezes Hospital Rates 91
Doctor Mufson Presents Paper in Norway 92
Anesthesiologists to Meet June 3-4 92
Collection Service Outlines Operation 93
Child Abuse CME Program 94
Special Departments
WVU Medical Center News xiv
Third-Party News, Views, Program Concerns xvi
Obituaries xviii
County Societies xix
Classified Section xxvii
Index To Advertisers xxviii
April, 1983, Vol. 79, No. 4
Roche salutes
the history of West Virginia medicine
THE FIRST STATE
INSTITUTION WEST
OF THE ALLEGHENIES
Mental health care in West Virginia began in 1858 —
before statehood— when the Virginia Assembly
authorized construction of the first public institution
west of the Alleghenies, at Weston. 1
Completed by West Virginia, it opened in 1864 as
the Trans-Allegheny Lunatic Asylum, consisting of three
one-story buildings housing nine patients. The asylum
was virtually the only tangible property West Virginia
had to show for its share of the disputed Virginia debt
of more than 13 million dollars at the end of the War
Between the States. 1
supplied the institution's kitchen.' To this day, Weston
Hospital, as it is now known, maintains its own
laundry, plumbing, maintenance and repair shops on
spacious grounds. 2
More important, it has served — and continues to
serve — the mental health requirements of the people
of West Virginia with the most advanced skills and
sciences. In 1957, Weston reached a remarkable
capacity of 2300 patients 2 — a far cry from the original
nine — a tribute to the growth of this historically
significant hospital.
Copyright © 1983 by Roche Products Inc. All rights reserved
A self-sufficient institution
By 1880, the main building had grown to nine acres
of floor space — a handsome gray stone structure said
to be the largest hand-cut stone building in the
country. Planned to be as self-sufficient as possible,
the main building was set on a 350-acre farm that
References: 1 . Writers' Program West Virginia A Guide to the Mountain State
New York, Oxford University Press, 1956, p. 363. 2. Data on file, Hoffmann-
La Roche Inc., Nutley, NJ.
The West Virginia Medical Journal
Official Publication of the West Virginia State Medical Association
POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324
Telephone (304) 346-0551
© 1983, West Virginia State Medical Association
EDITOR
Stephen D. Ward, M. D. (1984)
Wheeling
MANAGING EDITOR AND
BUSINESS MANAGER
Mr. Charles R. Lewis
Charleston
EXECUTIVE ASSISTANT
Mr. Custer B. Holliday
Charleston
ASSOCIATE EDITORS
David Z. Morgan, M. D. (1983)
Morgantown
John M. Hartman, M. D. (1985)
Charleston
Vernon E. Duckwall, M. D. (1986)
Elkins
Thomas J. Holbrook, M. D. (1987)
Huntington
L. Walter Fix, M. D. (1988)
Martinsburg
Joe N. Jarrett, M. D. (1989)
Oak Hill
Published monthly by the West
Virginia State Medical Association
under the direction of the Publica-
tion Committee. Original articles are
accepted on condition that they are
contributed solely to The Journal.
Postmaster send form 3579 to
The West Virginia Medical Journal,
P. O. Box 1031, Charleston, WV
25324.
Entered as second-class matter
January 1, 1926, at the post office
at Charleston, West Virginia, under
the act of March 3, 1879.
Subscription Rates: $10 a year in
the U.S.A.; $15 in foreign countries;
$2 per single copy. Advertising rates
furnished on request. Address all
communications to Business Manager,
The West Virginia Medical Journal,
Box 1031, Charleston, West Virginia
25324. Phone 346-0551.
Microfilm editions beginning with
the 1972 volume are available from
University Microfilms, Inc., 300 N.
Zeeb Road, Ann Arbor, Michigan
48106.
MEMBER, WEST VIRGINIA
PRESS ASSOCIATION, 1983
USPS 676 740
ISSN 0043 - 3284
CONTENTS
Scientific Articles
Hypokalemic Myopathy In Hyperemesis Gravi-
darum: Its Historical Significance — Jack E.
Riggs, M. D.; Robert C. Griggs, M. D.; and Ludwig
Gutmann, M. D. 95
Diagnosis And Treatment Of Alzheimer’s Disease —
M. K. II asan, M. D.; Nancy L. Slack, A.C.S.W.; and
Roger P. Mooney, M. A. 98
The President’s Page
The ‘Cost Containment’ (?) Bill — Harry Shannon,
M. D., President. W. Va. State Medical Association 104
Editorials
More On DRGs 105
The Patient, Or The System? 105
General News
FMG Group President Convention Keynoter 107
Continuing Education Activities 108
Wildwater Medical-Surgical Conference 109
Group Endorses Insanity Defense 110
Review A Book 110
Residencies For MU Graduates Announced 111
Majority of WVU Grads Choose Primary Care 111
New Patient Record Law Effective in June 112
Spring Meeting of Council 113
Special Departments
WVU Medical Center News xvi
Third-Party News, Views, Program Concerns xviii
Obituaries xx
County Societies xxiii
Classified Section xxix
Index To Advertisers xxx
May, 1983, Vol. 79, No. 5
v
THE ARMY NEEDS
PHYSICIANS
PART-TIME.
The Army Reserve offers you an excellent
opportunity to serve your country as a physician and
a commissioned officer in the Army Reserve Medical
Corps. Your time commitment is flexible, so it can fit
into your busy schedule. You will work on medical
projects right in your community. In return, you will
complement your career by working and consulting
with top physicians during monthly Reserve meetings
and medical conferences. You will enjoy the benefits
of officer status, including a nomcontributory retirement
annuity when you retire from the Army Reserve,
as well as funded continuing medical education pro-
grams. A small investment of your time is all it takes
to make a valuable medical contribution to your com-
munity and country. For more information, simply
call the number below.
ARMY RESERVE.
BE ALL YOU CAN BE.
Southern West Virginia
MAJ. Sheila T. Bowman, ANC
USAR AMEDD Procurement
Forest Glen Section
Walter Reed Army Medical Center
Washington, DC 20307
(301) 427-5101/5131
Northern West Virginia
MAJ. James E. Kuza, MSC
USAR AMEDD Procurement
Federal Building, Room 304
1 000 Liberty Avenue
Pittsburgh, PA 15222
(412) 391-2279/2289
The Vest Vinpia flcdical Journal
Official Publication of the West Virginia State Medical Association
POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324
Telephone (304) 346-0551
© 1983, West Virginia State Medical Association
EDITOR
Stephen D. Ward, M. D. (1984)
Wheeling
MANAGING EDITOR AND
BUSINESS MANAGER
Mr. Charles R. Lewis
Charleston
EXECUTIVE ASSISTANT
Mr. Custer B. Holliday
Charleston
ASSOCIATE EDITORS
David Z. Morgan, M. D. (1983)
Morgantown
John M. Hartman, M. D. (1985)
Charleston
Vernon E. Duckwall, M. D. (1986)
Elkins
Thomas J. Holbrook, M. D. (1987)
Huntington
L. Walter Fix, M. D. (1988)
Martinsburg
Joe N. Jarrett, M. D. (1989)
Oak Hill
Published monthly by the West
Virginia State Medical Association
under the direction of the Publica-
tion Committee. Original articles are
accepted on condition that they are
contributed solely to The Journal.
Postmaster send form 3579 to
The West Virginia Medical Journal,
P. O. Box 1031, Charleston, WV
25324.
Entered as second-class matter
January 1, 1926, at the post office
at Charleston, West Virginia, under
the act of March 3, 1879.
Subscription Rates: $10 a year in
the U.S.A.; $15 in foreign countries;
$2 per single copy. Advertising rates
furnished on request. Address all
communications to Business Manager,
The West Virginia Medical Journal,
Box 1031, Charleston, West Virginia
25324. Phone 346-0551.
Microfilm editions beginning with
the 1972 volume are available from
University Microfilms, Inc., 300 N.
Zeeb Road, Ann Arbor, Michigan
48106.
CONTENTS
Scientific Articles
Value and Limitations of the Noninvasive Labora-
tory: Experience With Over 5,000 Patients — Ali
F. AbuRahma, M. D.; and Linda Osborne, L.P.N. 139
Tuberculosis After Jejunoileal Bypass Surgery —
Leeman P. Maxwell, M. D.; Rashida A. Khakoo, M. D.;
and Edwin J. Morgan, M. D. 147
The President’s Page
The Role of Our Organization — Harry Shannon,
M. D.. President, W. \ a. State Medical Association 150
Editorials
Quality Commitment 151
New Resources 152
Single Issue 152
General News
Cardiovascular Disease Convention Topic 153
Saturday Convention Dinner Added 154
Continuing Education Activities 155
Cancer Reference Manual Offered 156
Association Names Scholarship Winners 157
Special Departments
WVU Medical Center News xvi
Third-Party News, Views, Program Concerns xviii
Obituaries xix
County Societies xix
MEMBER, WEST VIRGINIA 1982 ANNUAL AUDIT xxii
PRESS ASSOCIATION, 1983
Classified Section xxv
USPS 676 740
ISSN 0043 - 3284 INDEX To ADVERTISERS XXvi
July, 1983, Vol. 79, No. 7
v
Roche salutes
the history of West Virginia medicine
THE FIRST STATE
INSTITUTION WEST
OF THE ALLEGHENIES
Mental health care in West Virginia began in 1858 —
before statehood-— when the Virginia Assembly
authorized construction of the first public institution
west of the Alleghenies, at Weston. 1
Completed by West Virginia, it opened in 1864 as
the Trans-Allegheny Lunatic Asylum, consisting of three
one-story buildings housing nine patients. The asylum
was virtually the only tangible property West Virginia
had to show for its share of the disputed Virginia debt
of more than 13 million dollars at the end of the War
Between the States. 1
supplied the institution's kitchen. 1 To this day, Weston
Hospital, as it is now known, maintains its own
laundry, plumbing, maintenance and repair shops on
spacious grounds. 2
More important, it has served — and continues to
serve — the mental health requirements of the people
of West Virginia with the most advanced skills and
sciences. In 1957, Weston reached a remarkable
capacity of 2300 patients 2 — a far cry from the original
nine — a tribute to the growth of this historically
significant hospital.
A self-sufficient institution
By 1880, the main building had grown to nine acres
of floor space — a handsome gray stone structure said
to be the largest hand-cut stone building in the
country. Planned to be as self-sufficient as possible,
the main building was set on a 350-acre farm that
References: 1. Writers' Program West Virginia A Guide to the Mountain State
New York, Oxford University Press, 1956. p 363 2. Data on file, Hoffmann-
La Roche Inc , Nutley, NJ
Copyright © 1983 by Roche Products Inc All rights reserved
The Vest Virginia Tledical Journal
Official Publication of the West Virginia State Medical Association
POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324
Telephone (304) 346-0551
© 1983, West Virginia State Medical Association
EDITOR
Stephen D. Ward, M. D. (1984)
Wheeling
MANAGING EDITOR AND
BUSINESS MANAGER
Mr. Charles R. Lewis
Charleston
EXECUTIVE ASSISTANT
Mr. Custer B. Holliday
Charleston
ASSOCIATE EDITORS
David Z. Morgan, M. D. (1983)
Morgantown
John M. Hartman, M. D. (1985)
Charleston
Vernon E. Duckwall, M. D. (1986)
Elkins
Thomas J. Holbrook, M. D. (1987)
Huntington
L. Walter Fix, M. D. (1988)
Martinsburg
Joe N. Jarrett, M. D. (1989)
Oak Hill
CONTENTS
Scientific Articles
Effect of Ethrane Supplementation on Intra-
PULMONARY SHUNTING IN DOGS ANESTHETIZED WlTH
Nitrous Oxide and Morphine — David F. Graf,
M. D.; and Lawrence M. Lavine, M. D. 159
Dopamine-Modulating Drugs, Amenorrhea-Galactor-
rhea and Neuropsychiatric Illnesses — Paul E.
Frye, M. D. 161
The President’s Page
Hanging Together — Harry Shannon, M. D.. President,
W. Va. State Medical Association 166
Editorials
Positive Year 167
Public Trust 168
Published monthly by the West
Virginia State Medical Association
under the direction of the Publica-
tion Committee. Original articles are
accepted on condition that they are
contributed solely to The Journal.
Postmaster send form 3579 to
The West Virginia Medical Journal,
P. O. Box 1031, Charleston, WV
25324.
Entered as second-class matter
January 1, 1926, at the post office
at Charleston, West Virginia, under
the act of March 3, 1879.
Subscription Rates: $10 a year in
the U.S.A.; $15 in foreign countries;
$2 per single copy. Advertising rates
furnished on request. Address all
communications to Business Manager,
The West Virginia Medical Journal,
Box 1031, Charleston, West Virginia
25324. Phone 346-0551.
Microfilm editions beginning with
the 1972 volume are available from
University Microfilms, Inc., 300 N.
Zeeb Road, Ann Arbor, Michigan
48106.
MEMBER, WEST VIRGINIA
PRESS ASSOCIATION, 1983
USPS 676 740
ISSN 0043 - 3284
General News
116th Annual Meeting 169
Continuing Education Activities 171
New Association Members 173
Review A Book 174
Auxiliary Completes Meeting Plans 175
Doctor Fix Heads State Presidents Group 175
Convention Program 177
A Word of Thanks 180
Delegates and Alternates 181
Auxiliary Program 183
Scientific Exhibits 185
Annual Reports 188
Special Departments
WVU Medical Center News xii
Third-Party News, Views, Program Concerns xiv
Obituaries xv
County Societies xv
Classified Section xxi
Index To Advertisers xxii
August, 1983, Vol. 79, No. 8
THE ARMY NEEDS
PHYSICIANS
PART-TIME.
The Army Reserve offers you an excellent
opportunity to serve your country as a physician and
a commissioned officer in the Army Reserve Medical
Corps. Your time commitment is flexible, so it can fit
into your busy schedule. You will work on medical
projects right in your community. In return, you will
complement your career by working and consulting
with top physicians during monthly Reserve meetings
and medical conferences. You will enjoy the benefits
of officer status, including a non-contributory retirement
annuity when you retire from the Army Reserve,
as well as funded continuing medical education pro-
grams. A small investment of your time is all it takes
to make a valuable medical contribution to your com-
munity and country. For more information, simply
call the number below.
ARMY RESERVE.
BE ALL YOU CAN BE.
Southern West Virginia Northern West Virginia
MAJ. Sheila T. Bowman, ANC MAJ. James E. Kuza, MSC
USAR AMEDD Procurement USAR AMEDD Procurement
Forest Glen Section Federal Building, Room 304
Walter Reed Army Medical Center 1000 Liberty Avenue
Washington, DC 20307 Pittsburgh, PA 15222
(301) 427-5101/5131 (412) 391-2279/2289
The Vest Virginia ricdical Journal
Official Publication of the West Virginia State Medical Association'
POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324
Telephone (304) 346-0551
© 1983, West Virginia State Medical Association
EDITOR
Stephen D. Ward, M. D. (1984)
Wheeling
MANAGING EDITOR AND
BUSINESS MANAGER
Mr. Charles R. Lewis
Charleston
EXECUTIVE ASSISTANT
Mr. Custer B. Holliday
Charleston
ASSOCIATE EDITORS
David Z. Morgan, M. D. (1983)
Morgantown
John M. Hartman, M. D. (1985)
Charleston
Vernon E. Duckwall, M. D. (1986)
Elkins
Thomas J. Holbrook, M. D. (1987)
Huntington
L. Walter Fix, M. D. (1988)
Martinsburg
Joe N. Jarrett, M. D. (1989)
Oak Hill
CONTENTS
Scientific Articles
Public Health Legacy of the Vietnam War: Post-
Traumatic Stress Disorder and Implications for
Appalachians — Daniel Sumrok, B. A.; Steven L.
Giles, Ph.D.; and Mildred Mitchell-Bateman, M. D. 191
Practical Tips on Adverse Drug Effects in Glau-
coma Therapy — Larry T. Schwab, M. D. 199
The President’s Page
Strategy For Change — Carl R. Adkins, M. D., Presi-
dent, W. Va. State Medical Association 202
Editorials
DRG Concerns 203
Child Safety 203
Successful Cost Control Provider-Motivated 204
‘Positive Futurist’ 204
Published monthly by the West
Virginia State Medical Association
under the direction of the Publica-
tion Committee. Original articles are
accepted on condition that they are
contributed solely to The Journal.
Postmaster send form 3579 to
The West Virginia Medical Journal,
P. O. Box 1031, Charleston, WV
25324.
Entered as second-class matter
January 1, 1926, at the post office
at Charleston, West Virginia, under
the act of March 3, 1879.
Subscription Rates: $10 a year in
the U.S.A.; $15 in foreign countries;
$2 per single copy. Advertising rates
furnished on request. Address all
communications to Business Manager,
The West Virginia Medical Journal,
Box 1031, Charleston, West Virginia
25324. Phone 346-0551.
Microfilm editions beginning with
the 1972 volume are available from
University Microfilms, Inc., 300 N.
Zeeb Road, Ann Arbor, Michigan
48106.
MEMBER, WEST VIRGINIA
PRESS ASSOCIATION, 1983
USPS 676 740
ISSN 0043 - 3284
General News
Mid-Winter Conference Lineup 205
New Marshall Class Has 48 Students 206
Hal Wanger Family Practice Program 206
Hypertension Program September 14 208
Group Management Meeting in September 208
Health Care Coverage Urged For Jobless 209
New WVU Charleston Division Staff Members 209
Hospital Reps Meet With AMA Council 210
New WVU Class of 88 Announced 211
MU Surgery, Educational Skills Programs 212
Gastroenterology Update October 5 213
State Money Woes Hit Medical Services 213
Doctors’ Medicaid Pay Public Information 214
Special Departments
WVU Medical Center News xviii
Third-Party News, Views, Program Concerns xx
Obituaries xxi
Classified Section xxix
Index To Advertisers xxx
September, 1983, Vol. 79, No. 9
v
Roche salutes
the history of West Virginia medicine
THE FIRST STATE
INSTITUTION WEST
OF THE ALLEGHENIES
Mental health care in West Virginia began in 1858 —
before statehood — when the Virginia Assembly
authorized construction of the first public institution
west of the Alleghenies, at Weston. 1
Completed by West Virginia, it opened in 1864 as
the Trans-Allegheny Lunatic Asylum, consisting of three
one-story buildings housing nine patients. The asylum
was virtually the only tangible property West Virginia
had to show for its share of the disputed Virginia debt
of more than 13 million dollars at the end of the War
Between the States. 1
supplied the institution's kitchen. 1 To this day, Weston
Hospital, as it is now known, maintains its own
laundry, plumbing, maintenance and repair shops on
spacious grounds. 2
More important, it has served — and continues to
serve — the mental health requirements of the people
of West Virginia with the most advanced skills and
sciences. In 1957, Weston reached a remarkable
capacity of 2300 patients 2 — a far cry from the original
nine — a tribute to the growth of this historically
significant hospital.
A self-sufficient institution
By 1880, the main building had grown to nine acres
of floor space — a handsome gray stone structure said
to be the largest hand-cut stone building in the
country. Planned to be as self-sufficient as possible,
the main building was set on a 350-acre farm that
References: 1. Writers' Program West Virginia A Guide to the Mountain State
New York, Oxford University Press, 1956, p 363 2. Data on tile, Hoffmann-
La Roche Inc , Nutley. NJ
Copyright © 1983 by Roche Products Inc All rights reserved
The West Virginia Hectical Journal
Official Publication of the West Virginia State Medical Association
POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324
Telephone (304) 346-0551
© 1983, West Virginia State Medical Association
EDITOR
Stephen D. Ward, M. D. (1984)
Wheeling
AAANAGING EDITOR AND
BUSINESS AAANAGER
AAr. Charles R. Lewis
Charleston
EXECUTIVE ASSISTANT
AAr. Custer B. Holliday
Charleston
ASSOCIATE EDITORS
David Z. AAorgan, AA. D. (1983)
AAorgantown
John AA. Hartman, AA. D. (1985)
Charleston
Vernon E. Duckwall, AA. D. (1986)
Elkins
Thomas J. Holbrook, AA. D. (1987)
Huntington
L. Walter Fix, AA. D. (1988)
AAartinsburg
Joe N. Jarrett, AA. D. (1989)
Oak Hill
Published monthly by the West
Virginia State AAedical Association
under the direction of the Publica-
tion Committee. Original articles are
accepted on condition that they are
contributed solely to The Journal.
Postmaster send form 3579 to
The West Virginia AAedical Journal,
P. O. Box 1031, Charleston, WV
25324.
Entered as second-class matter
January 1, 1926, at the post office
at Charleston, West Virginia, under
the act of AAarch 3, 1879.
Subscription Rates: $10 a year in
the U.S.A.; $15 in foreign countries;
$2 per single copy. Advertising rates
furnished on request. Address all
communications to Business AAanager,
The West Virginia AAedical Journal,
Box 1031, Charleston, West Virginia
25324. Phone 346-0551.
AAicrofilm editions beginning with
the 1972 volume are available from
University AAicrofilms, Inc., 300 N.
Zeeb Road, Ann Arbor, AAichigan
48106.
MEMBER, WEST VIRGINIA
PRESS ASSOCIATION, 1983
USPS 676 740
ISSN 0043 - 3284
CONTENTS
Scientific Articles
Carbon Dioxide Laser in Otolaryngology: Head and
Neck Surgery — Romeo Y. Lim, M. D. 215
Sonographic Antepartum Diagnosis of Dicephalus
Dipus Dibrachius: Two Case Reports — Katrina J.
Garten, RDMS; K. F. Rawlinson, M. D.; and Robert
P. Pulliam, M. D. 218
Scientific Department
Medical Grand Rounds From the West Virginia Uni-
versity Medical Center (Osteoporosis) — Edited
by Irma H. Ullrich, M. D. 221
The President’s Page
A Time For Action — Carl R. Adkins, M. D., President,
W. Va. State Medical Association 228
Editorials
Work To Be Done 229
The Public Factor 230
Concern For Quality 230
General News
Dr. Carl R. Adkins Assumes Presidency 231
Doctor Holroyd Named To Honorary AMA Post 232
Membership Amendments Adopted 233
17th Mid-Winter Clinical Conference 236
Mrs. T. Keith Edwards Heads Auxiliary 239
Association Has Heavy Workload 240
Doctor Adkins: ‘Strategy For Change’ 241
Medical Program Payments On Schedule 242
Special Departments
WVU Medical Center News xviii
Third-Party News, Views, Program Concerns xx
Obituaries xxiii
Necrology Report xxvi
Resolutions xxvii
Classified Section xxxiii
Index To Advertisers xxxiv
October, 1983, Vol. 79, No. 10
Prescribed
For
Security
Sound coverage begins with a
sound carrier. As a specialist in
professional liability insurance,
ICA has earned its enviable
performance record through
selective underwriting and
unexcelled claims defense. This
solid record of achievement has
enabled ICA to successfully expand
to over 30 states across the nation.
Our comprehensive, affordable
coverage is designed to eliminate
headaches and unnecessary
expenses. For professional liability
insurance with no side effects,
contact: Insurance Corporation of
America, ICA Center, 4295 San
Felipe, P.O. Box 56308, Houston,
Texas 77256. Phone 1-800-231-2615;
in Texas call 1-800-392-9702.
K/l
The Specialist in Professional
Liability Insurance.
The West Virginia Medical Journal
Official Publication of the West Virginia State Medical Association
POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324
Telephone (304) 346-0551
© 1983, West Virginia State Medical Association
EDITOR
Stephen D. Ward, M. D. (1984)
Wheeling
MANAGING EDITOR AND
BUSINESS MANAGER
Mr. Charles R. Lewis
Charleston
EXECUTIVE ASSISTANT
Mr. Custer B. Holliday
Charleston
CONTENTS
Scientific Articles
Limb Preservation in Extremity Osteosarcoma —
Eric T. Jones, M. D.. Ph.D.; and J. David Blaha, M. D. 265
1983 Van Liere Memorial Student Research Con-
vocation, WVU School of Medicine 270
ASSOCIATE EDITORS
David Z. Morgan, M. D. (1983)
Morgantown
John M. Hartman, M. D. (1985)
Charleston
Vernon E. Duckwall, M. D. (1986)
Elkins
Thomas J. Holbrook, M. D. (1987)
Huntington
L. Walter Fix, M. D. (1988)
Martinsburg
Joe N. Jarrett, M. D. (1989)
Oak Hill
Published monthly by the West
Virginia State Medical Association
under the direction of the Publica-
tion Committee. Original articles are
accepted on condition that they are
contributed solely to The Journal.
Postmaster send form 3579 to
The West Virginia Medical Journal,
P. O. Box 1031, Charleston, WV
25324.
Entered as second-class matter
January 1, 1926, at ^the post office
at Charleston, West Virginia, under
the act of March 3, 1879.
Subscription Rates: $10 a year in
the U.S.A.; $15 in foreign countries;
$2 per single copy. Advertising rates
furnished on request. Address all
communications to Business Manager,
The West Virginia Medical Journal,
Box 1031, Charleston, West Virginia
25324. Phone 346-0551.
Microfilm editions beginning with
the 1972 volume are available from
University Microfilms, Inc., 300 N.
Zeeb Road, Ann Arbor, Michigan
48106.
MEMBER, WEST VIRGINIA
PRESS ASSOCIATION, 1983
USPS 676 740
ISSN 0043 - 3284
Scientific Department
Medical Grand Rounds From The West Virginia Uni-
versity Medical Center (Drug Use in The
Elderly) — Edited by Irma H. Ullrich, M. D. 275
The President’s Page
The Myth of Medicare — Carl R. Adkins, M. D., Presi-
dent, W. Va. State Medical Association 280
Editorials
Unique Assignment 281
Other Forces 281
Communications 282
General News
Conference Panelists, Speaker on Disability 283
Review A Book 285
Continuing Education Activities 286
MCI Announces Sports Medicine Conference 286
Self-Assessment Computer Courses 288
Special Departments
WVU Medical Center News xiv
Third-Party News, Views, Program Concerns xvi
Obituaries xviii
County Societies xxi
Book Review xxiv
1983 Annual Index xxvii
Classified Section xxix
Index To Advertisers xxx
December, 1983, Vol. 79, No. 12
v
Prescribed
For
Security
Sound coverage begins with a
sound carrier. As a specialist in
professional liability insurance,
ICA has earned its enviable
performance record through
selective underwriting and
unexcelled claims defense. This
solid record of achievement has
enabled ICA to successfully expand
to over 30 states across the nation.
Our comprehensive, affordable
coverage is designed to eliminate
headaches and unnecessary
expenses. For professional liability
insurance with no side effects,
contact: Insurance Corporation of
America, ICA Center, 4295 San
Felipe, P.O. Box 56308, Houston,
Texas 77256. Phone 1-800-231-2615;
in Texas call 1-800-392-9702.
IOV
The Specialist in Professional
Liability Insurance.
The West VirgiDia ttedical Journal
Vol. 79, No. 1 January, 1983
Postmastectomy Breast Reconstruction*
GEORGE B. IRONS, M. D.
Section of Plastic and Reconstructive Surgery, Mayo
Clinic and Mayo Foundation, Rochester, Minnesota
Postmastectomy breast reconstruction is ap-
propriate and worthwhile for any patient with a
good prognosis who strongly desires reconstruc-
tion. With the several techniques available,
reasonably good results generally can be obtain-
ed. Examples of those various techniques are
presented, discussed and illustrated.
T^ACH year in the United States approximately
100,000 women are diagnosed as having
breast cancer. Most of these women will be
treated surgically. The resultant deformity is a
heavy burden for these women to bear the rest
of their lives. In the past, their options have
been either to do nothing or to wear an external
prosthesis. More recently, a third option, which
is more acceptable to many women, is surgical
breast reconstruction.
Breast reconstruction, owing to a number of
factors, has become more accepted. First, the
ablative surgery has become less radical because
the disease is diagnosed at an earlier stage than
previously: and, with proper case selection, the
results with preservation of the pectoral muscles
and enough skin for closure are as good as they
are with radical removal of these structures. Ad-
junctive irradiation and chemotherapy have
improved the survival of patients with cancers
of stages II and higher.
Second, technical progress in breast recon-
struction now permits reconstruction in almost
“Presented at the William E. Irons, M. D., Surgical
Symposium, Marshall University School of Medicine,
Huntington, West Virginia, September 8, 1980.
any patient with an acceptable result. With the
development of silicone prostheses and the de-
sign of new flaps, the reconstructive procedure
has become less complicated, and the results
are more acceptable.
Third, patient awareness and acceptance of
breast reconstruction is increasing. As one pa-
tient said. “The mastectomy may have saved my
life, but the reconstruction made it worth living.”
The woman who has undergone reconstruction
feels more feminine and more secure socially
and sexually.
The advantages of breast reconstruction are
that the reconstructed breast is incorporated in
the bodv image whereas the external prosthesis
is not, clothes are easier to fit, and there is more
freedom of movement without fear of dislodg-
ment of an external prosthesis.
Indications
Almost any patient with a favorable prognosis
who desires breast reconstruction and who is
an acceptable operative risk is a candidate for
reconstruction. The main considerations are the
pathology of the tumor, the treatment given, and
the time interval since treatment. The pathology
is important because reconstruction generally
should be undertaken only in the patient who
has a good prognosis, that is, one who has stage
I disease or stage II disease with three or less
positive low axillary nodes.
The patient should have had adequate treat-
ment and, if irradiation or chemotherapy is
being used as an adjunct to surgery, reconstruc-
tion should be delayed until this treatment is
completed.
January, 1983, Vol. 79, No. 1
1
The timing of reconstruction requires two con-
siderations: the time when the tissues in the
mastectomy area will be healed enough for re-
construction, and the length of time one should
watch for recurrence before proceeding with
reconstruction. While reconstruction can be
done any time after mastectomy, most surgeons
desire to wait until the wound is well-healed and
the scars have matured, about six months after
mastectomy. In regard to the length of time one
should watch for recurrence before proceeding
with reconstruction, obviously, the longer one
waits the better. Most recurrences are noted
during the first two years. Many patients, how-
ever, do not want to wait that long before
reconstruction and, since the incidence of local
recurrence is low for stage I disease, reconstruc-
tion can proceed as soon as the tissues are suit-
able.
Essentials of Breast Reconstruction
Thorough Analysis of the Patient : The history
should include the tumor pathology, extent of
spread and treatment given. The mastectomy
side should be examined for any residual disease
and for suppleness of the skin, scar and pectoral
muscle. The other breast should be examined
for breast disease, and its size and shape should
Figure 1. A. After modified radical right mas-
tectomy. B. After reconstruction on right side using
available tissue and submuscular silicone implant.
Subcutaneous mastectomy and submuscular implant
were performed on left side.
be noted. A thorough analysis of the patient and
her disease helps determine whether she is a
candidate for breast reconstruction and the
method that is most appropriate.
Careful Planning and Execution: After de-
termining the anatomic situation in a given pa-
tient, the surgeon should discuss the options for
reconstruction. This discussion always involves
reconstructing a breast mound on the mastectomy
side. Reconstruction also may involve a nipple-
areolar complex, infraclavicular fullness, or an-
terior axillary fold, depending on what tissues
have been removed and what the patient wants
replaced. The other breast should be considered
at the same time because the most important
anatomic goal is symmetry; frequently, the other
breast will have to be reshaped to match the
reconstructed breast. Also, the possibility of
cancer developing in the other breast is a con-
cern to most patients. It should be assumed
that whatever factors were responsible for the
cancer in one breast are still operating against
the second breast.
Other factors are the pathology of the cancer,
family history, and the presence of disease in
the other breast. Lobular carcinoma has a 30-
per cent incidence of bilaterality. If the patient’s
Figure 2. A. After modified radical left mastec-
tomy. B. After reconstruction using a thoraco-
epigastric flap and submuscular silicone implant on
the left and subcutaneous mastectomy and sub-
muscular implant on the right.
2
The West Virginia Medical Journal
Figure 3. A. After modified radical mastectomy
on the right. B. After reconstruction using latis-
simus dorsi myocutaneous flap and silicone implant
on the right.
mother had breast cancer, the risk is doubled.
If the other breast has disease such as duct
epithelial hyperplasia, bloody nipple discharge,
or extensive fibrocystic disease, the risk of can-
cer is increased. In these situations, subcutane-
ous mastectomy of the remaining breast should
be considered.
After both sides have been evaluated and the
options discussed with the patient, the method
of reconstruction can be determined. A success-
ful outcome depends on whether the patient
understands what can and cannot be accomplish-
ed by the operation. Various methods of recon-
struction can be used, but generally, the method
should he the simplest and safest one that will
give an acceptable result. The breast mound is
replaced by a silicone prosthesis. This must be
covered by healthy skin and. preferably, by
healthy muscle. If the pectoralis muscle is
present and the skin is adequate, the simplest
method of reconstruction is the creation of a
submuscular pocket into which a silicone pros-
thesis is placed I Figure 1).
If muscle or skin is not available and ade-
quate, then cover for the prosthesis will have to
be provided by a flap. The possibilities are the
thoraco-epigastric flap, 1,2 which can provide
Figure 4. A. After right radical mastectomy. B.
After reconstruction using omentum and skin graft
to cover silicone implant.
skin (Figure 2); the latissimus dorsi flap, 3 ' 5
which can provide skin and muscle (Figure 3);
and the omentum, 6 which can provide cover that
will accept a skin graft (Figure 4). The latis-
simus dorsi flap is the most versatile and de-
pendable and. consequently, is the most fre-
quently used method for supplying soft-tissue
replacement.
After the mastectomized side has been recon-
structed, attention is then directed to the other
side. In some cases, nothing may be required.
More often, though, a mastopexy, reduction
mastectomy, or subcutaneous mastectomy will be
necessary. Again, one should strive for as much
symmetry as possible. The main determinants
of symmetry are size, shape and position of the
inframammary lines.
Construction of a nipple-areola should be de-
ferred until after the wounds are well-healed
and the tissues have settled in place; this usually
requires 10 to 12 weeks. One can then best
determine the proper location for the nipple-
areola. Various methods have been employed
for this, hut the best results have been obtained
by a method that utilizes similar tissues for each
side. One can make two areolae from one intact
areola (Figure 5), or one can transfer medial
January, 1983, Vol. 79, No. 1
3
thigh skin to the breast as a skin graft (Figure
6). For the nipple, a graft from the intact nip-
ple can be used, or if there is no intact nipple,
labia minora tissue can be used for both sides.
Follow-Up and Revisions : For optimal results,
the surgeon and the patient must be willing to
Figure 5. Reconstructed nipple-areoia on left
using shared tissue from normal right side.
Figure 6. Reconstructed nipple areola using
medial thigh skin for areola and free graft from
opposite nipple.
follow up the surgery with periodic evaluations.
For most patients, minor adjustments or re-
visions of the reconstruction need to be made.
In many, these revisions may be done at the
same time as the nipple-areolar construction.
Complications
The potential complications of these pro-
cedures should be discussed with every patient
before operation. Postoperative bleeding and in-
fection may occur after any surgery. Necrosis
of skin flaps, implant extrusion, and capsule
contracture are possible hazards with breast re-
construction, although they are not common,
especially if the prosthesis is placed submuscu-
larly. There is a possibility that reconstruction
can cover up local recurrence; however, when
the prosthesis is placed behind skin, sub-
cutaneous tissue and muscle, recurrence in these
tissues is easily palpable.
References
1. Tai Y, Hasegawa H: A transverse abdominal flap
for reconstruction after radical operations for recurrent
breast cancer. Plast Reconstr Surg 1974; 53:52-54.
2. Cronin TD, Upton J, McDonough JM: Recon-
struction of the breast after mastectomy. Plast Reconstr
Surg 1977; 59:1-14.
3. Olivari N: The latissimus flap. Br J Plast Surg
1976; 29:126-128.
4. Bostwick J III, Vasconez LO, Jurkiewicz MJ:
Breast reconstruction after a radical mastectomy. Plast
Reconstr Surg 1978; 61:682-693.
5. Maxwell GP, McGibbon BM, Houpes JE: Vas-
cular considerations in the use of a latissimus dorsi
myocutaneous flap after a mastectomy with an axillary
dissection. Plast Reconstr Surg 1979; 64:771-780.
6. Arnold PG, Hartrampf CR, Jurkiewicz MJ: One-
stage reconstruction of the breast, using the transposed
greater omentum: Case report. Plast Reconstr Surg
1976; 57:520-522.
4
The West Virginia Medical Journal
Popliteal Vascular Trauma In Skiers
WALTER B. BLUM, M. D.
ROBERT A. ROSE, M. D.
Elkins, West Virginia
During the ivinter of 1980 and 1981, two
cases of popliteal vascular trauma incurred by
skiers were treated at the Memorial General
Hospital in Elkins, West Virginia. These two
cases are reported with particular attention to
the management of these complex injuries.
V/Tost reported traumatic injuries to the popli-
teal artery in a civilian setting occur from
penetrating wounds due to single, low-velocity
missiles. A significant number of popliteal
arterial injuries also result from blunt trauma,
usually caused by motor vehicle accidents. 1 This
is a report of two cases of popliteal vascular
trauma associated with injuries to the knee in-
curred while skiing.
Case One
A 21-year-old white female sustained blunt
trauma to the right knee while skiing. On ad-
mission to the hospital, the right lower extremity
was grossly deformed. The right popliteal pulse
was absent, as were the right dorsalis pedis and
posterior tibial pulses. The patient was taken
promptly to the operating room where operative
arteriography documented an obstruction of flow
at the mid-popliteal artery level. The popliteal
space was explored through a posterior “S”-
shaped incision, with the patient positioned in
the prone position on the operating room table.
A large hematoma was evacuated from the
popliteal space. The gastrocnemius and plantaris
muscles were noted to have been avulsed from
their origins. The popliteal artery was noted to
be crushed for a one and one-half inch segment
near the mid-portion of its passage through the
popliteal space.
A primary repair of the injured segment was
not technically possible. Accordingly, a short
segment of saphenous vein was prepared from
the contralateral lower extremity. A two-inch
segment of popliteal artery was resected. The
reversed saphenous vein was interposed between
the two sections of normal popliteal artery. Both
anastomoses were performed with #4-0 Ethilon.
Distal embolectomy with Fogarty embolectomy
catheters was performed and followed by flush-
ing with Heparin/ Saline solution. Excellent
distal popliteal, dorsalis pedis, and posterior
tibial pulses were noted immediately after the
arterial circulation had been restored. Multiple
fasciotomies were performed in the calf region.
External Skeletal Fixation
When the vascular repair was completed, an
external skeletal fixation was employed to main-
tain reduction of the dislocated knee, with the
knee flexed approximately 20 to 30 degrees.
This was then reinforced with a padded cylinder
cast.
Postoperatively, the patient exhibited swelling
of the right lower extremity, particularly in the
foot and calf regions; however, the peripheral
pulse remained excellent, and the foot remained
warm and pink. There was some impairment of
dorsiflexion. indicating injury to the peroneal
nerve. Non-weight-bearing crutch walking was
instituted one week after surgery. Twelve days
after surgery, the patient was transferred by
plane out of state to convalesce with her family
in her hometown.
Case Two
A 16-year-old white male struck his right knee
against a stationary object at high speed while
skiing. On admission to the hospital, he was
noted to have a massively swollen, cold, and
cyanotic right lower extremity from the mid-
thigh downward. No popliteal, dorsalis pedis,
or posterior tibial pulses were detectable by
palpation or doppler. Complete instability of
the knee joint was noted. The patient had no
motor function of the right foot, and was
anesthetic from the mid-ankle downward.
The patient was taken quickly to the operating
room and placed in the supine position, with the
hip abducted and the knee joint maintained in
20 to 30 degrees flexion. The popliteal space
w r as explored through the medial approach.
When the popliteal space was opened, a great
deal of bleeding was noted. Complete disruption
of both the popliteal artery and popliteal vein
was discovered.
Vascular control proximally and distally was
obtained using Rummel tourniquets. A suitable
length of saphenous vein was removed from the
contralateral leg: and. after the damaged seg-
ments of popliteal artery and vein were resected,
a saphenous vein interposition was used to re-
establish flow to the right lower extremity.
January, 1983, Vol. 79, No. 1
5
Reconstructions Flushed
Local Heparin/Saline injection was used to
flush both arterial and venous reconstructions.
Both were performed using #5-0 Ethilon. Both
were end-to-end everting anastomoses. Just prior
to the completion of the arterial anastomosis,
the embolectomy catheter was passed through
the distal arterial tree to remove debris and
clots in this region. Once the anastomoses were
completed, excellent distal popliteal, dorsalis
pedis, and posterior tibial pulses were noted—
both by palpation and by doppler.
These excellent pulses remained so throughout
the patient’s postoperative course. The extremity
promptly became warm and pink. The popliteal
region exhibited extensive soft tissue damage,
with the posterior knee capsule being completely
disrupted. Associated tendons and ligaments
were markedly deformed and swollen. No
obvious identifiable peripheral nerve tissue was
observed at this time. The posterior fascial
compartment was widely open because of the
massive injury.
An anterior compartment fasciotomy was then
performed because of severe swelling in this
region. At this point, the knee joint was stablized
with the application of an external fixation de-
vice. This device was tailored for the needs of
local wound care and produced satisfactory
stability, but this was less than optimal because
of the needs of wound care. Because of massive
swelling, no cast was applied.
Skin Sutures Removed
Twenty-four hours after surgery, the swelling
was noted to be so marked that it necessitated
removal of skin sutures from the medial and
lateral incisions; however, the vascular struc-
tures remained covered by muscle. The lower
extremity remained anesthetic from the right
ankle on downward. Frequent local wound care
was performed using a sterile technique with the
application of Betadine-soaked dressings over the
medial and lateral incisions.
By the fifth postoperative day, the patient was
considered sufficiently stable to be transferred
by air ambulance out of state to a medical center
close to his residence for the remainder of his
care.
Discussion
Mechanism of Injury :
The mechanism of injury for most civilian
blunt traumatic vascular injuries to the popliteal
region involves physical contact between a mov-
ing object and a stationary patient. In the case
of the skier, the roles are reversed as he is the
moving object who usually strikes a sationary
structure, producing sudden hyperextension of
the knee (Figure 1) with such force as to pro-
duce a range of vascular damage varying from
arterial intimal disruption all the way to com-
plete transsection of the popliteal artery and
vein. There is a range of associated injuries
from partial to complete disruption of the knee
joint, with or without fracture dislocation of the
femur, tihia, and fibula. Peripheral nerve injury
also is frequentlv associated.
Clinical Findings:
In both cases, the clinical examination dis-
closed obvious evidence of vascular injury:
absent pulses, cool temperature, severe pain,
pallor, absence of capillary filling, and signifi-
cant swelling and deformity at the level of the
knee joint. Many authors 1,2,3 stress the urgency
of prompt resuscitation and rapid transport from
the site of injury to the operating room where
restoration of circulation to an ischemic ex-
tremity can begin expeditiously.
The first case was in the operating room eight
hours after injury, and the second case, five
hours after injury. The delay encountered in
these two cases was related to the geographic
remoteness of the area where the injury occurred
and the time necessary to arrange transportation
to the hospital. Preoperative arteriography was
performed in the first case, and documented the
level of arterial obstruction. In the second case,
it was felt that the injury was so obvious as to
the level of vascular damage that arteriography
would simply delay ultimate restoration of flow
to a profoundly ischemic leg.
Operative Management:
Two surgical approaches have been described
extensively. 1,3 The posterior approach, usually
6
The West Virginia Medical Journal
with the patient in the prone position, was used
successfully in the first case. In the second case,
the medial approach proved advantageous with
the patient in the supine position and the hip
abducted. The medical approach is preferred
when there are concomitant thoracic and
abdominal injuries requiring urgent care. In
both cases, segmental resection of the damaged
vessel was necessary. In the first case, this was
the popliteal artery I Figure 2). In the second
case, this was both the popliteal artery and vein
i Figure 3).
In both cases, primary end-to-end anastomosis
of the damaged vessel was not possible because
of the length of traumatized vessel. An appro-
priate length of autogenous vein graft was re-
moved from the contralateral extremity and used
successfully in each case. In the second case,
autogenous saphenous vein graft was considered
necessary as there was no deep venous conduit
remaining; and, with the massive swelling at the
time of surgery, it was doubtful that a simple
arterial repair in the absence of a venous repair
w r ould remain patent. A failure here would re-
sult in inevitable limb loss and amputation. 4 In
this case, the use of the contralateral saphenous
vein was dictated by the need to maintain the
ipsilateral saphenous vein as a critically neces-
sary source of venous return.
Systemic heparinization was not used in either
case, and was contraindicated in the second
case because of massive adjacent musculoskeletal
injury. Frequent local Heparin flushes to the
distal arterial tree and distal catheter embolec-
tomy were performed prior to the completion of
the arterial anastomosis in each case. Distal
fasciotomies were required in both cases be-
cause of massive swelling and long interval of
ischemia to the extremities. Skeletal fixation by
external means was used in both instances and
was considered essential to the ultimate success
of the vascular repair, as well as extremity
stabilization.
Results
The major goal was limb salvage, and this was
indeed successful in both cases; however, signifi-
cant morbidity remained, particularly in the
second case. Limb swelling resolved slowly in
each case. Musculoskeletal problems related to
the knee joint instability remained in each case
and will require additional corrective surgery.
Neurologic deficits also were a problem. In the
first case, peroneal palsy was present. In the
second case, there was no motor or sensory
PROXIMAL
POPLITEAL
ARTERY
PROXIMAL
POPLITEAL
VEIN
SAPHENOUS
VEIN
SEGMENT
SAPHENOUS
VEIN
SEGMENT
DISTAL
POPLITEAL
ARTERY
DISTAL
POPLITEAL
VEIN
Figure 3.
January, 1983, Vol. 79, No. 1
7
function from the ankle on downward. This case
may require peripheral nerve grafting in the
future. At the present time, this patient is
ambulatory with the aid of a brace.
One-Year Followup
At one year after surgery, both patients have
undergone successful orthopedic reconstructions
of the affected knee joint to improve stability
and range of motion. Both patients continue
to have good peripheral pulses, and are ambu-
latory, but require bracing of the affected ex-
tremity because of the persistence of neurologic
deficits.
References
1. Snyder III WH, Watkins WL et ah: Civilian pop-
liteal artery traumas An eleven-year experience with
eighty-three injuries. Surgery 1979; 85:101-8.
2. Daugherty EM, Sachatello CR et ah: Improved
treatment of popliteal artery injuries. Arch Surg 1978;
113:1317-21.
3. Abernathy C, Dickinson TC et ah: Management
of popliteal artery injuries. Surg Clin 1979; 59:507-18.
4. Rich NM, Collins GJ et ah: The effect of acute
popliteal venous interruption. Ann Surg 1976; 183:365-
8 .
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Journal should be typewritten, triple-spaced, on one side only of firm (no
onion skin or flimsy), standard letter sized ( 8 Y 2 by 11 in.) white paper.
Wide margins (at least 114 in. on left) should be left free of typing. On
the first or title page should be shown the title of the article, the name (or
names) of the author, and his degrees. Pages should be numbered consecu-
tively, the page number being shown in the right upper corner along with
the surname of the author.
Where reference is made to generically-designated drugs, the first such
reference must be followed by parentheses containing the most commonly
known trade-name drug of that designation. In addition, a listing of all generic
drugs mentioned in the article, with their trade-name equivalents, should
appear at the end of the article.
A short abstract summarizing the manuscript should be included. This
should be typed in double space on a separate page.
Authors are requested to submit a carbon copy with the original.
Illustrations should be numbered and their approximate locations shown
in the text. Each should be identified by placing on its back the author’s
name, its number and an indication of its “top.” Drawings and charts in-
tended for reproduction should be done in black (India) ink on pure white.
Photographs should be on glossy paper and minimum of about 5 by 7 in.
in size. Cost of printing black and white photos in excess of 4 will be billed to
author, and no more than 25 references will be published free of charge
to the author. A legend should be provided for each illustration and, preferably,
attached to it.
All scientific material appearing in The Journal is reviewed by the
Editorial Board. Manuscripts should be mailed to The Editor, West Virginia
Medical Journal, Box 1031, Charleston, W. Va. 25324.
8
The West Virginia Medical Journal
Special Article
Emergency Maternal Transfer: An Ounce of Prevention
For West Virginia Newborns
ROSALIND PARKINSON, M.A.
Department of Community Medicine, West Virginia
University School of Medicine, Morgantown
ROBERT C. NERHOOD, M. D.
Department of Obstetrics and Gynecology, Marshall
University School of Medicine, Huntington, West Vir-
ginia
Maternal transfer has occurred at an increas-
ing rate in West Virginia since 1978. As a re-
sult, a higher proportion of the state’s small pre-
matures are note born in perinatal centers. These
infants have experienced lower mortality rates
than those born in other hospitals.
* | 'he late 1970s has been a time of accelerated
improvement in West Virginia’s infant mor-
tality rate (Figure). Much of the increased
infant survival is associated with collaborative
efforts to regionalize perinatal intensive care on
a statewide basis.
Beginning with transfer of sick newborns to
three tertiary centers in 1975, the perinatal pro-
gram progressed in 1978 to organized transfer
of mothers before delivery if there were indica-
tions of impending problems for unborn in-
fants.* Maternal transfers increased from 104
patients in 1978 to 213 patients in 1980 when
they comprised 28 per cent of all perinatal re-
ferrals (Table 1).
Vital statistics suggest that maternal referral
in West Virginia conforms to the pattern re-
ported for other states where studies indicate
that most transfers result from signs of prema-
ture labor. 1 While there has been little change
in the number of small prematures born in West
Virginia, the proportion of these infants born in
perinatal centers nearly doubled since maternal
transfer has become a viable option (Table 2).
Problems in Procedure
Maternal transfer to improve pregnancy out-
come is recommended by organized medicine
°The West Virginia perinatal program is sponsored by
the West Virginia Department of Health in cooperation
with three informally designated perinatal centers in-
cluding Charleston Area Medical Center, West Virginia
University Medical Center and Cabell-Huntington Hos-
pital.
and government agencies alike. 2,3 However,
while it has been demonstrated that there is im-
proved neonatal survival through maternal trans-
fer, problems relating to the procedure spark
considerable controversy. 4,5 Women object to
transfer from a supportive community environ-
ment to an unfamiliar perinatal center. The
determination of the need for and the timing of
maternal transfer is difficult for physicians.
Transfer during early stages of premature labor
is often delayed in the hope that labor can be
stopped; when premature labor is well advanced,
there is a hesitancy to initiate maternal trans-
fer for fear of a precipitous delivery en route to
the perinatal center. Sometimes there have
been experiences of transfers where neither ma-
ternal nor infant transfer was in fact necessary.
Figure. Infant deaths/1,000 live births. United
States and West Virginia, 1946-1980.
Sources :
1) Vital Statistics of the U.S., 1946-1978.
2) Monthly Vital Statistics Report, Annual Summary for
1979, DHHS Pub #(PHS) 81-1120.
3) Health Statistics Center, West Virginia Department
of Health, Vital Statistics 1965-1979.
4) 1980 Provisional Data NCHS and West Virginia
Health Statistics Center.
January, 1983, Vol. 79, No. 1
9
TABLE 1
Perinatal Transfers to Charleston Area Medical
Center, West Virginia University Hospital and
Cabell-Huntington Hospital, 1974-1980
Total
Perinatal
# %
Before or
After Birth
Year
Antenatal
# %
Neonatal
# %
1974
43
100
NA°
0
43 100
1975
109
100
NA
0
109 100
1976
268
100
NA
0
268 100
1977
428
100
13
3
415 97
1978
556
100
104
19
452 81
1979
651
100
185
28
466 71
1980
763
100
213
28
550 71
“Not available
TABLE 2
Number and Per Cent of West Virginia Resident
Infants Weighing Less than 2,000 Grams Born in
West Virginia Perinatal Centers, 1974-1979
Infants less than 2,000 grams
Born in Perinatal Centers
Year
Number
Per cent of
State Total
1974
144
23
1975
143
23
1976
168
29
1977
220
34
1978
245
37
1979
292
45
TABLE 3
Births and Neonatal Deaths Among
Less>-than-2,000-Gram Infants by Hospitals
Where Births Occurred, 1977-1979
Infants less than 2,000 grams
Hospitals
Live
Births
Neonatal Deaths/ 1,000
Deaths Live Births
Community Hospitals
1192
323
271.0
Perinatal Centers
757
146
192.9
Totals
1949
469
240.6
These drawbacks to maternal transfer are
balanced by an awareness that, when born in a
community hospital, critically ill neonates re-
quiring immediate and prolonged supportive
care must await transfer to a perinatal center.
Even though labor and delivery room personnel
may have been trained in various technical pro-
cedures, e.g., infant resuscitation, infrequent ex-
posure to neonatal stress may result in less than
optimal performance in an emergency. In con-
trast, personnel in perinatal centers manage
problems of compromising illness in newborns
on a virtually daily basis.
Survival Rate Better
West Virginia’s infant mortality statistics
show that premature infants are more likely to
survive when they are born in perinatal centers.
The mortality rate among small prematures born
in community hospitals was 40 per cent higher
than among those born in perinatal centers in
1977-79 (Table 3). The difference in these
weight-specific mortality rates suggests that the
medical environment of an infant’s birthplace
can play an important role in determining life
or death. For this reason, it is to be hoped that
maternal transfer will continue and perhaps
occur even more often in the coming years.
References
1. Giles HG, Isaman J, Moore WJ, Christian CD:
The Arizona high-risk maternal transport system: An
initial view. Am J Obstet Gynecol 1977; 128: 400-407.
2. Committee on Perinatal Health: Toward Improv-
ing the Outcome of Pregnancy, Recommendations for the
Regional Development of Maternal and Perinatal Health
Services, the National Foundation March of Dimes, New
York, 1977.
3. Guidelines for the Improved Pregnancy Outcome
Program permitted federal support for emergency ma-
ternal transfer only. No other patient care expenses were
allowable under the program.
4. Harris TR, Isaman J, Giles HR: Improved neo-
natal survival through maternal transport. Obstet Gynecol
1978; 52 (3): 294-300.
5. Auld PAM: Maternal transport is not the answer.
Perinatology-Neonatalogy 1978; 2(2) :8.
10
The West Virginia Medical Journal
A Continuing Medical Education Event!
The 16 th Mid-Winter Clinical
Conference
Charleston Marriott Hotel
309 Lee Street, East, Charleston, WV
January 21-23
West Virginia State Medical Association
West Virginia University School of Medicine
Marshall University School of Medicine
WATCH THE JOURNAL FOR PROGRAM DETAILS
THE PROGRAM CHAIRMAN is Joseph T. Skaggs, M. D., of Charleston. Other members of the Pro-
gram Committee are William O. McMillan, Jr., M. D., and C. Carl Tully, M. D., both of Charleston;
Maurice A. Mufson, M. D., Huntington; Robert L. Smith, M. D., Morgantown, and Richard C. Starr,
M. D., Beckley.
THE REGISTRATION FEE of $50 for the entire conference will be charged all registrants except
nurses, medical students, interns and residents. Advance registration is requested, and please make checks
payable to “WEST VIRGINIA STATE MEDICAL ASSOCIATION.”
ACCREDITATION: Attendance will be acceptable for 14 hours of Category 1 credit toward the
Physician’s Recognition Award of the American Medical Association; and the program also is acceptable
for 13 Prescribed hours by the American Academy of Family Physicians.
OVERNIGHT ACCOMMODATIONS: Physicians should communicate directly with the reservation
manager of the hotel or motor inn of their choice. The Charleston Marriott was holding a block of rooms
for conference attendees through January 3, but reservations after that date may be requested on a space-
available basis. In order to obtain group rates, those who make reservations directly with the head-
quarters hotel should specify that they will be attending the Mid-Winter Clinical Conference. Group rates
are $48 for a single room and $54 for a double. Those who register in advance for the Conference with
the State Medical Association (see below) will receive from the Association a postage-paid Marriott reser-
vation request card specifically designated for Mid-Winter Clinical Conference registrants.
FOR ADVANCE REGISTRATION, please complete the form below and mail to: WEST VIR-
GINIA STATE MEDICAL ASSOCIATION, P. O. BOX 1031, CHARLESTON, W. VA. 25324.
Please register me for the 16th Mid-Winter Clinical Conference in Charleston, WV, January 21-23.
My $50 registration fee is (is not) enclosed.
Name (please print )
Specialty
Address
City
January, 1983, Vol. 79, No. 1
11
*Jhe PzeAident
<7% meAAage from . . .
HIGH COST OF DEFENSIVE MEDICINE
/ T"*HIS month, I would like again to address the
A broad issue of cost of health care. This topic
has been very prominent in the news recently.
It is obviously one of the prime concerns of the
national administration and our state govern-
ment, as well as private citizens and the medical
profession.
We understand from statistics compiled by the
U. S. Department of Health and Human Services
that total health care expenditures, public and
private, rose 15.1 per cent from 1980 to 1981.
We also note, although this is not emphasized,
that health care expenditures have been rising
steadily since Congress created Medicare and
Medicaid in 1965 and, a figure noted but not
emphasized, the average increase from 1976 to
1981 was 13.9 per cent. I am at a loss to see
how politicians this year panic over the differ-
ential increase of 1.2 per cent from the average
1976 to 1981 figures, especially as HHS states
price inflation was responsible for 70 per cent of
the increase, and aging of the population for 20
per cent of the increase. Perhaps the reason is
that approximately 42.8 per cent of total health
care cost was spent by Federal, state and local
governments, according to their figures. Perhaps
their concerns stem from the realization that the
promises they made regarding health care in the
past decade are coming home to haunt them, and
the bill is far higher than they had anticipated.
Be that as it may, I would like to address an-
other aspect of the cost of medicine which has
not been looked at by the politicians, bureaucrats
and regulators in their attempt to control the ris-
ing cost of health care. This is the field of de-
fensive medicine — the tests that are done not for
good clinical reasons but in order to protect the
practitioner from legal action and t,o insure that
if legal action is commenced he will be found to
have done as much or more than one could or
should do.
The rationale for ordering these defensive tests
and procedures may be indefensible clinically.
but it certainly is defensible from a practical,
legalistic point of view. One has only to look at
the ever-increasing amounts of money awarded to
plaintiffs (and incidentally, plaintiffs’ lawyers)
for relatively minor problems. Examples, such as
$800,000 for a misplaced navel or $150,000 be-
cause of a scar at an IV site, abound; therefore,
the reason for ordering ETKTM (Every Test
Known To Man ) to CYA ( Cover Your A- ) is ap-
parent.
I read with interest in the media that physi-
cians' fees rose approximately 9.8 per cent this
year while inflation is predicted to be 5-6 per
cent and, therefore, our fees are considered to be
excessive. Nowhere, however, do I read certain
other figures. For example, medical malpractice
insurance will average increases in the range of
25 per cent in our state for next year, and utility
fees, prices of supplies, and of our phone service
show no signs of decreasing, regardless of the
decrease in tffe CPI.
This leads me to believe that a good place to
halt the rate of increase in medical care would
be to have some attention from the politicians,
bureaucrats, regulators and media to provide tort
reform to help decrease at least one parameter of
the ever-increasing spiral of costs. After all,
physicians’ costs, like any other professionals’,
are passed along to our patients, for we have no
other sources of revenue. EUtimately, if govern-
ment at all levels pays 42.8 per cent of the bill,
the cost of these exhorbitant awards is borne by
every taxpayer, and this is the fact that needs to
be brought to his or her attention.
Harry Shannon, M. D., President
West Virginia State Medical Association
12
The West Virginia Medical Journal
The Vest Virginia fledical Journal
Editorials
The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or
in communications submitted to this Journal for publication. The author shall be held entirely responsible.
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State
Medical Association.
In the news section of The Journal is a story
outlining proposed State Medical Association
positions, and efforts to seek passage of several
measures, in the upcoming legislative session to
begin January 12.
The Association again will be in a posture
established and maintained effectively over the
past several years — one of offering
GENERAL ideas of its own with respect to pro-
QUARTERS moting the general health and wel-
fare. It proposes to be aggressive in
espousing those views — and that's where the
general membership must play a role.
Bills related to health and medical care have
mushroomed in lawmiaking bodies across the
nation in the last decade or so, beginning with
far-reaching measures introduced into, and fre-
quently enacted by, the Congress.
Some of that legislation is not consistent with
such things as cost effectiveness in the true sense
of the word — a proper blending of reasonable
efforts to blunt costs but at the same time pro-
tecting the availability of, and access to, quality
care.
That general problem certainly will be a major
one with which physicians and others must deal,
and play an active role in. during the upcoming
session. As always at this time of year, doctors
are urged to stay abreast of legislative develop-
ments, and in contact with their legislators. The
doctors in practice are the constituency of those
senators and delegates, not the State Medical
Association headquarters.
Every effort will be made, through legislative
bulletins and other means, to keep the Associa-
tion membership informed on as current a basis
as possible. But we plead with you to heed those
communications, and immediately speak out if
you see any problems or have questions.
In other words, were again going to "general
quarters,’' heading into mid-January. This alert
needs to be constantly in your minds — and you
need to be ready as your help might be needed.
Anywhere a physician might care to look
these days, he or she can find a new study or
survey related to medical or health care. Some
of the results might appear positive,
SURVEYS others just the opposite — all of which
underlines the crazy times in which
we live.
Many of the surveys have been by American
Medical Association components, and one re-
cently determined that the public had strong
pro-physician attitudes on professional liability
issues. Most people didn't think malpractice
suits usually were justified, although 47 per cent
held the opposite view.
The majority I 61 per cent ) of the respon-
dents in 1.504 telephone interviews favored
limits on malpractice awards (something that
generally has not been looked upon w r ith favor
by the courts across the land I . Forty-seven per
cent of the public respondents thought current
awards have run too high, with seven per cent
saying not high enough.
Ninety-two per cent of the 1,000 physician
respondents in the AMA survey rated better
physician-patient rapport as a very effective
method for reducing professional liability risk.
No other proposals for reducing risks — such as
more peer review, continuing medical education
and risk management seminars — got more than
a 38-per cent approval rate.
On average, physicians surveyed estimated
that 22 per cent of malpractice claims result
from actual negligence. Most physicians ( 62
per cent ) said hospital staffs should require evi-
dence of professional liability insurance for staff
privileges.
Then there was another recent AMA survey
of physicians showing a growing concern over
January, 1983, Vol. 79, No. 1
13
competition in medicine. An increasing number
of physicians believed there are too many doc-
tors in their communities: 33 per cent in 1981
and 40 per cent in 1982.
Fewer than half the physicians surveyed (47
per cent) have been experiencing an increasing
patient load in the last few years, and only about
one-third (35 per cent) reported their incomes
increasing.
Thirty-nine per cent said unemployment les-
sened their patient load; 67 per cent reported
that unemployment had lessened the ability of
patients to pay. A current or impending surplus
of doctors was foreseen by 72 per cent of those
surveyed.
The AMA surveying group concluded that,
taken in combination, the study’s findings in-
dicated competition for patients was increasing
among physicians, and was having a definite im-
pact on medical practice in the nation.
What about concerns regarding medical costs?
In still another AMA study, results showed that
such concern was growing among physicians and
the general public alike. Physician concern over
costs increased sharply over a one-year period,
while concern about government regulation or
access to medical care dropped correspondingly.
(We’d suggest that, in the wake of recent con-
gressional action and a flood of new Department
of Health and Human Services regulations, feel-
ings about regulation will do another turnabout
in the next survey.)
Telephone interviews with randomly selected
physicians showed 58 per cent listing cost to be
the main problem facing medicine today. Last
year, the figure was 44 per cent. In 1,504 tele-
phone interviews with public respondents also
selected at random, 62 per cent — as compared to
55 per cent last year — said cost was the main
problem facing health care and medicine.
The survey found that almost half (47 per
cent) of the American people believed that not
enough of society’s resources is being directed
to health care, and only 16 per cent felt too much
is being spent.
But is health care the public’s highest priority
when it comes to spending more money? No.
Public respondents gave a higher ranking to
education, the environment and financial assist-
ance to the poor.
All of these survey results will mean somewhat
different things to different people. But one of
the findings again sticks out like a mountain,
and for the third time in this month’s editorials
we must emphasize it. It’s doctor-patient rap-
port.
The House Staff Council at the Charleston
Area Medical Center organized something new
this year, at least for that institution. It was
a multidisciplinary conference on
MEDICAL “Medical Pearls, ’’.with some 15 medi-
PEARLS cal specialists presenting short, clini-
cally useful bits of information.
The subjects ranged from nephrology to
various aspects of surgery; from pulmonary
medicine to obstetrics; and from platelets to
vertigo. Perhaps other medical staffs in the state
conduct similar conferences, although the CAMC
presentations were set up largely for senior
medical students and residents. If not, they
might want to consider at least the general idea.
Along with observations and subjects directly
related to day-to-day practice were reviews of
new technology and thinking. And there like-
wise were some expressions of what commonly
can be called good old-fashioned “horse sense.”
One internist told the audience to always keep
foremost in mind affability, along with ability
and availability, in professional relationships
with patients.
Humor is very important in the practice of
medicine, and if you cannot convey an image of
humor, a smile is the next best thing, he said.
As for one who finds friendliness beyond his
capabilities, it must be back to the proverbial
drawing board.
Listen to your patients, said another physi-
cian, because they usually will tell you what
you need to know — even though you might have
to listen “between the lines" to hear it.
He emphasized that “the family can either be
your worst enemy or your greatest friend." both
in encouraging patient compliance and (along
with nurses, secretaries and others ) in observing
the patient outside the confines of the examining
room or office.
Old hat, you say, with respect to these kinds
of “pearls?” Rapport is never old hat. It re-
mains the cornerstone of the doctor-patient re-
lationship, a fact never more apparent than in
today’s complex life patterns.
14
The West Virginia Medical Journal
GENERAL NEWS
Sports Medicine Specialist,
Attorney To Speak
A University of Virginia physician who has
received numerous awards in the field of sports
medicine will be a member of the faculty for the
16th Mid-Winter Clinical Conference, the Pro-
gram Committee announced.
The annual continuing education program
will begin at 2 P. M. on Friday, January 21,
at the Marriott Hotel
in Charleston, and end
at noon on Sunday.
The faculty will con-
sist of 13 principal
speakers for sessions
Friday afternoon and
evening, Saturday
morning and after-
noon, and Sunday
morning.
Sponsors are the
State Medical Associa-
tion and the Marshall
University and West
Virginia University School of Medicine.
“We believe we have an outstanding faculty,
and we have tried to provide many of the sub-
jects requested by doctors.'’ said Joseph T.
Skaggs, M. D., Charleston. Chairman of the
Program Committee.
Dr. Frank C. McCue III. a native of Max-
welton. Greenbrier County, and a member of the
medical staff at the University of Virginia in
Charlottesville, will speak on “Sports Medicine
for the Family Physician" during the Saturday
morning session. He is Director, Hand Surgery
and Sports Medicine Division, Department of
Orthopedics and Rehabilitation, at the Uni-
versity, and also is Team Physician for the
Athletic Department.
Among a number of sports medicine awards
received by Doctor McCue are the National
Distinguished Service Award from the National
High School Coaches Association in appreciation
for interest in the care of high school athletes
(1977); Certificate of Appreciation from the
Medical Society of Virginia for recognition of
Gary A. Banas, L.L.B.
contributions to Sports Medicine in Virginia
I 1979); and the National Athletic Trainers As-
sociation President’s Challenge Award for 1980.
Also Public Session Speaker
Doctor McCue also will be the speaker for
the public session Friday evening. “Medical
Care for the Athlete — What You Should Know”
will be the title of his talk.
As announced previously, a physicians’ ses-
sion on “The Doctor, Quality Control and Pro-
fessional Liability” will be held concurrently
with the public session Friday evening. Gary
A. Banas, an Akron. Ohio, attorney, will be the
principal speaker. Doctor Skaggs, w'ho is
Director of Medical Affairs at Charleston Area
Medical Center (CAMC), will preside.
Panelists will be Tom Auman, Director of
Professional Liability, McDonough Caperton
Shepherd Group. Charleston; Fred Bockstahler,
J.D., Director of Patient Affairs, CAMC; James
C. Crews, CAMC President; Jack Leckie, M. D.,
Huntington, Chairman of the Committee on In-
surance, West Virginia State Medical Associa-
tion, and John F. Wood, J.D.. Huntington at-
torney.
Lt. Colonel Fred Donohoe, Chief of the West
\ irginia State Police, the Program Committee
also announced, will make brief remarks during
the Saturday morning session. Colonel Donohoe
will talk about efforts to secure state funds in
1983 to expand and continue the pilot State
Police MEDEVAC air medical rescue program
which otherwise expires this month. (See story
elsewhere in this issue of The Journal.)
‘Meet the Faculty’
Other features of the conference will be 5
o’clock “Meet the Faculty” cash bars following
the afternoon session on Friday and Saturday,
I I scientific exhibits, and meetings of other
medical groups as listed in the program.
Doctor McCue is a Diplomate of the American
Board of Orthopedic Surgery, and a Fellow of
the American Society of Surgery of the Hand,
American Academy of Orthopedic Surgery,
American College of Surgeons, and American
Society of Sports Medicine. He was a founding
January, 1983, Vol. 79, No. 1
15
member of the American Orthopedic Society for
Sports Medicine.
Doctor McCue received his undergraduate and
M. D. ( 1956 ) degrees from the University of
Virginia. He interned at the Kansas University
Medical Center, took a residency in orthopedic
surgery at the University of Virginia, and
studied surgery of the hand for two years under
physicians in Los Angeles.
He is the author or co-author of some 70
scientific articles, and chapters in six books.
Other Speakers
The other previously-announced speakers and
topics are:
Friday Afternoon : “Diagnostic Tests in
Hepatitis” — Robert H. Waldman, M. D., WVU
Professor of Medicine and Acting Dean, School
of Medicine, Morgantown; “Vaccines in the
Treatment of Hepatitis” — Larry I. Lutwick, As-
sociate Professor of Medicine, State University
of New York, Downstate Medical School: and
Associate Director, Department of Medicine,
and Director, Division of Infectious Diseases.
Maimonides Medical Center, Brooklyn; and
“Herpes” — Jack M. Bernstein, M. D., ML! As-
sistant Professor of Medicine;
Saturday Morning: “Trauma Transport” —
James W. Kessel, M. D., Charleston surgeon;
and “Joint Replacement" — J. David Blaha,
M. D., WVU Assistant Professor, Department
of Orthopedic Surgery; and Chief, Section of
Arthritis Surgery, Morgantown;
Saturday Afternoon: “New Developments in
Prenatal Diagnosis” — R. Stephen S. Amato,
M. D., Ph.D., WVU Professor of Pediatrics and
Medical Director, Affiliated Facility for De-
velopmentally Disabled, Morgantown: “Heritable
Immunodeficiency Disease — New Prospec-
tives” — Martin R. Klemperer, M. D., MU Pro-
fessor and Chairman, Department of Pediatrics;
and “Nephrotic Syndrome in Children” —
Roberta Gray, M. D., MU Associate Professor of
Pediatrics;
Lens Replacement
Sunday Morning: “Lens Replacement”
George W. Weinstein, M. D., WVU Professor
and Chairman, Department of Ophthalmology,
Morgantown; “Use and Abuse of Tricyclic Anti-
depressants” — William H. Nelson, M. D., As-
sociate Professor of Psychiatry, University of
Connecticut, Farmington; and Chief, Ambulatory
and Consultation Psychiatry, Veterans Admini-
stration Medical Center, Newington, Connecticut;
and “Calcium Channel Blockers” — Robert C.
Touchon, M. D., MU Associate Professor of
Medicine and Chief of Cardiology, Department
of Medicine.
Presiding physicians in addition to Doctor
Skaggs will be Maurice A. Mufson, MU Profes-
sor and Chairman, Department of Medicine
(Friday Afternoon); Tony C. Majestro, Charles-
ton. WVU Clinical Associate Professor, Depart-
ment of Orthopedic Surgery (Friday Evening
Public Session ) ; Thomas F. Scott, Huntington,
MU Clinical Associate Professor of Surgery
(Saturday Morning); Herbert H. Pomerance,
Chairman, Department of Pediatrics, CAMC,
and Professor and Director of Pediatrics, WVU
Charleston Division (Saturday Afternoon); and
John W. Traubert, WVU Professor and Chair-
man. Department of Family Practice, Morgan-
town ( Sunday Morning ) .
Other Meetings
Other meetings scheduled at the Marriott in
conjunction with the conference include the
Family Medicine Foundation of West Virginia,
Thursday evening, January 20; Board of Di-
rectors, West Virginia Chapter, American
Academy of Family Physicians, Friday evening;
West Virginia State Society of Anesthesiologists,
Saturday noon; WESPAC dinner, Saturday even-
ing, and the State Medical Association's Cancer
Committee, Sunday morning.
Speakers for the WESPAC dinner will be
Peter B. Lauer. Executive Director and Treasurer
of AMPAC ( American Medical Political Action
Conference Exhibits
Physicians and others attending the 16th
Mid-Winter Clinical Conference will have the
opportunity to see some 11 scientific exhibits.
Exhibitors scheduled to date include:
West Virginia Department of Health;
American Heart Association, West Virginia
Affiliate; Family Medicine Foundation of
West Virginia; McDonough Caperton Shep-
herd Association Group: Nationwide Insur-
ance — Medicare; American Cancer Society,
West Virginia Division, Inc., Kanawha
County Unit; Kanawha County Chapter,
Physicians for Social Responsibility; Allergy
Rehabilitation Foundation, Inc.; West Vir-
ginia Lung Association, Inc.; J. B. Lippincott,
Division of Harper and Row, Pittsburgh; and
Medical Publisher’s Representative, Inc.,
Cincinnati.
16
The West Virginia Medical Journal
Committee ) and W. Leonard Weyl, M. D., of
Arlington. Virginia, AMPAC Board member.
The program meets the criteria for 14 hours
of credit in Category 1 of the Physician’s
Recognition Award of the American Medical
Association, and is approved for 13 Prescribed
hours by the American Academy of Family
Physicians.
A registration fee of $50 will be charged all
registrants except nurses, medical students, in-
terns and residents. For advance registration,
make checks payable to West Virginia State
Medical Association, and mail to the Association
at P. 0. Box 1031, Charleston 25324.
Hotel Reservations
The Charleston Marriott was holding a block
of rooms for conference attendees through
January 3, but reservations after that date may
be requested on a space-available basis. Those
making reservations — in order to receive group
rates — should specify that they will be attending
the Mid-Winter Clinical Conference. Group
rates are $48 for a single room and $54 for a
double.
Other members of the Program Committee
are Drs. William 0. McMillan. Jr., and C. Carl
Tully, both of Charleston; Richard G. Starr,
Beekley: Maurice A. Mufson. Huntington, and
Robert L. Smith, Morgantown.
The Program Committee is receiving continu-
ing assistance from WVU Charleston Division
staff members J. Zeb Wright, Ph.D., Coordinator
of Continuing Education. Department of Com-
munity Medicine; and Sharon A. Hall, Con-
ference Coordinator.
Joint Appointment For MU,
Hospital Announced
The first joint faculty appointment for the
Marshall University School of Medicine and
Huntington State Hospital has been announced
by the two institutions.
Dr. Eric H. Sawitz, Assistant Professor of
Familv and Community Health, will spend 40
per cent of his time at the State Hospital, where
he will be responsible for three wards of develop-
mental^ disabled persons. He will work with
hospital staff to develop and expand services for
the patients.
“We all are interested in developing a relation-
ship between Huntington State and Marshall
which would improve patient care,” Doctor
Sawitz said.
Doctor Sawitz previously served as Medical
Director and internist at the Cabin Creek
Medical Center in Dawes, and received bis M. D.
in 1976 from Boston University. He has served
as a consultant in internal medicine for the West
Virginia Division of Vocational Rehabilitation,
and medical consultant and a member of the
board of the Kanawha County Special Olympics.
Huntington Burn Unit
Taking Referrals
A burn intensive care unit at Cabell-Hunting-
ton Hospital in Huntington is now in operation.
Designated for the specialized treatment of
patients from West Virginia, eastern Kentucky
and southwestern Ohio, the burn unit opened
formally in November.
The four-bed unit is housed adjacent to the
general intensive care unit in the critical care
wing. The phvsicial therapy (hydrotherapy)
room is in the unit, and isolation techniques
keep it apart from normal traffic patterns.
The planning and design of the unit began
in 1977 when the administrators of the hospital
took a bard look at its critical care units and
decided that, in addition to new facility con-
struction, it would provide a new service as well,
that of specialty care of the burn victim.
A group of surgeons, Marshall University
surgical residents, burn nurses, physical thera-
pists, dietitians, and social workers apply the
“burn team concept to the patient and his
family. The unusually severe disruption of the
family by this type of injury is appreciated by
the team, and was a compelling reason for the
hospital to provide an in-state service for West
\ irginia and tri-state residents, according to Dr.
James A. Coil. Jr., M. D., Professor of Surgery
at Marshall L^niversity School of Medicine, who
is Medical Director of the burn unit.
Referrals
Referring physicians can call the unit directly
at 1 304 ) 696-6107 for information or patient
transfer. In addition, a burn clinic meets for
the evaluation of long-term reconstruction and
rehabilitation of burn victims.
As a guideline for emergency referral, the
American Burn Association’s criteria for burn
unit admission apply; 1. partial-thickness injury
January, 1983, Vol. 79, No. 1
17
of more than 20 per cent body surface area; 2.
full thickness of more than 10 per cent of body
surface area; 3. full-thickness burns of the face,
hands, or feet; 4. inhalation injury; 5. serious
associated medical problems; and 6. electrical
burns.
The unit has the hope of being a resource
facility for the state, and members of the hospital
team are accepting invitations on a limited basis
to speak on burn care. An awareness that the
best burn treatment is prevention will be a major
thrust of future educational effort, said Doctor
Coil.
Doctor Reed, Past President,
Dies In Charleston
Thomas G. Reed of Charleston, President of
the State Medical Association in 1949, died
on December 7 at his
home. He was 84.
A retired urologist
and a native of Hardy
County, Doctor Reed
began practice in
Charleston in 1930.
Doctor Reed was a
member of the As-
sociation’s Council
from 1945 through
1948, and was an
Alternate Delegate to
the American Medical
Association in the
sixties.
He was a member of the former West Virginia
Medical Licensing Board from 1965 to 1970.
Doctor Reed was certified by the American
Board of Urology, a Fellow of the American
College of Surgeons, and a member of the
American Urological Association. He received
his M. D. degree in 1926 from Jefferson Medical
College in Philadelphia.
Doctor Reed was an honorary member, and
a Past President of, the Kanawha Medical
Society, and an honorary member of the West
Virginia State Medical Association and the
American Medical Association.
Surviving are the widow; two daughters, Mrs.
Frederick H. Belden, Jr., of Charleston and Mrs.
Gary C. Caylor of Houston, Texas; three sisters,
Mrs. Beulah Heltzel of Wardensville, Mrs. Essye
Bean of Moorefield and Mrs. Olga Walker of
Wheaton, Maryland, and six grandchildren.
Continuing Education
Activities
Here are the continuing medical education
activities listed primarily by the West Virginia
University School of Medicine for part of
1983, as compiled by Dr. Robert L. Smith,
Assistant Dean for Continuing Education, and
J. Zeb Wright, Ph. D., Coordinator, Con-
tinuing Education, Department of Community
Medicine, Charleston Division. The schedule is
presented as a convenience for physicians in plan-
ning their continuing education program. (Other
national, state and district medical meetings are
listed in the Medical Meetings Department of
The Journal. )
The program is tentative and subject to
change. It should be noted that weekly confer-
ences also are held on the Morgantown, Charles-
ton and Wheeling campuses. Further information
about these may be obtained from: Division of
Continuing Education. WVU Medical Center,
3110 MacCorkle Avenue, S. E., Charleston
25304: Office of Continuing Medical Education.
WVU Medical Center, Morgantown 26506; or
Office of Continuing Medical Education. Wheel-
ing Division, WVU School of Medicine, Ohio
Valley Medical Center. 2000 Eoff Street. Wheel-
ing 26003.
Jan. 24-28, Snowshoe. Fourth Mid-Winter Car-
diovascular Symposium
Feb. 6-9, Snowshoe, Surgical Conference
March 18, Charleston, 10th Annual Newborn
Day
March 25-26. Morgantown. Infection Control
Workshop
March 28-29, White Sulphur Springs, Sym-
posium on Tumors for the Orthopedic
Surgeon
Regularly Scheduled Continuing
Education Outreach Programs from
WVU Medical Center/
Charleston Division
Cabin Creek, Cabin Creek Medical Center,
Dawes, 2nd Wednesday, 8-10 A. M. — Jan.
12, “Recently Recognized Sexually-Trans-
mitted Diseases.” Thomas W. Mou, M. D.
Gassaway, Braxton Co. Memorial Hospital, 1st
Wednesday, 7-9 P. M. — Jan. 5, “Evaluation
& Management of Thyroid Nodules,” Richard
Kleinmann, M. D.
Thomas G. Reed, M. D.
18
The West Virginia Medical Journal
Feb. 2, “Yes, Virginia, There Are Venereal
Diseases in Rural Practices,” Patrick Robin-
son, M. D.
Welch, Stevens Clinic Hospital, 3rd Wednesday,
12 Noon-2 P.M. — March 16, “Protocols for
Treating Poisonous Snake Bites,” Edward
Wright, M. D.
Buckhannon, Madison, Oak Hill, Whitesville,
Williamson — I winter break in January).
Council Agenda Highlighted
By Legislative Issues
The Medical Association’s Council, acting on
recommendations of the Committee on Legisla-
tion’s steering subcommittee, has approved an
ambitious program for the 1983 state legislative
session to begin January 12.
Council directed preparation of eight hills,
mostly in the area of so-called tort reform re-
lated to professional liability, and voted support
of a measure to set up a simplified mechanism
for obtaining corneas for transplant.
It left to the judgment of the leadership and
the Committee on Legislation positions which
might be taken on bills in the area of hospital
rate setting and review, and hospital board
composition, once staff has an opportunity to
study measures actually introduced.
Bills Council directed prepared would:
Prohibit inclusion of a dollar amount in a
malpractice claim; tighten the statute of limita-
tions under which actions are brought; modify
the collateral source rule which now prohibits
evidence at trial of a patient’s compensation
from sources other than the defendant.
Payments for Future Damages
Mandate periodic payments for future dam-
ages; require juries to apportion damages among
defendants; establish a fee schedule for
attorneys’ fees based on amounts of recovery;
place a $250,000 maximum on recovery for pain
and suffering, and other-economic losses; and
provide by statute, with specific limitations,
procedures through which patients could obtain
copies or summaries of patient records.
In other action at its November 21 meeting.
Council:
— Elected to honorary membership, after
appropriate component society action, C. R.
Davisson. M.D.. of Weston: J. Carlton Godlove,
M. D.. Martinsburg, and Edward Gliserman.
M. D., Holden in Logan County.
— Adopted a “mission statement" reiterating
the Medical Association’s commitment to con-
tinuing medical education, and particularly to
its role as an accrediting arm of the national
Accreditation Council for Continuing Medical
Education ( ACCME ) with respect to such
intrastate programs as those reviewed and
approved at community hospitals.
— Approved for calendar and fiscal 1983 a
Medical Association operating budget of $494,-
505, a figure only $599 above the budget for
1982.
— Approved a survey of State Medical As-
sociation members as to ( 1 ) whether they favor
the concept of construction of an Association
headquarters building on property now owned
in Charleston; and (2) whether the members
would be willing to purchase tax-exempt in-
dustrial revenue bonds issued by West Virginia
State Medical Association Properties, Inc., to
finance such construction.
— Approved expenditures of up to $4,500 a
year from the Association’s operating funds, as
advances toward reimbursement, to cover
properties corporation expenses such as taxes,
audit costs and other minor items until that
corporation has its own financial operating plan.
— Approved endorsement of a collection
service offered by I.C. System, Inc., of St. Paul,
Minnesota, with a proviso that funds accruing
Dr. Alex Wanger of Martinsburg, center, and Dr.
William Wanger of Beckley were among partici-
pants at the recent 8th annual Hal Wanger Family
Practice Conference at the West Virginia University
Medical Center. The conference was named for
their father, an early leader in continuing medical
education in the state. The late Dr. Hal Wanger
inaugurated the Potomac-Shenandoah Valley Post-
graduate Institute, forerunner of the present con-
ference. Chatting with the Doctors Wanger is Brita
Nieland.
January, 1983, Vol. 79, No. 1
19
to the Medical Association as a result of the
endorsement he to the benefit of the properties
corporation.
- — Re-elected Joe N. Jarrett, M.D., of Oak Hill
to a new seven-year term on the Publication
Committee, with the term to begin January 1,
1983.
— Endorsed TEL-MED, a library of taped
telephone messages on a variety of health and
health-related topics for the general public.
Association Committee Hears
WVU Funding Review
The West Virginia University Medical School,
troubled by some 1982-83 budget reductions,
needs an additional legislative appropriation of
$8 to $9 million for next year just to keep pro-
grams at 1981 levels, John E. Jones, M. D., has
explained.
Doctor Jones, WVU’s Vice President for
Health Sciences, reviewed in detail the School
of Medicine’s budget request at a recent meet-
ing of the State Medical Association’s WVU
Liaison Committee in Bridgeport,
He noted that WVU has no remaining “bal-
ance forward’’ funds in its account to carry it
into the 1983-84 fiscal year, for which the Legis-
lature to convene January 12 will have to
fashion operating budgets for state departments,
agencies and institutions. The Medical Center
cut programs by $2.9 million in 1982-83.
A proposed two cents-a-bottle increase in the
state’s soft drinks tax — one source of funds for
the medical school — could produce an additional
$15 million a year, with half to be used for
operational purposes and half for capital ex-
penditures, Doctor Jones said.
Hospital Updating Needed
He explained that the aging West Virginia
L T niversity Hospital will require expenditures of
perhaps $30 million in the next few years to
bring it in line with current fire, safety and other
codes.
On a continuing somber note, Doctor Jones
said that a faculty movement projection as of
September 22, 1982, indicated a potential loss
this school year of 44 physicians for a variety of
reasons, including the salary structure and other
feelings of instability.
Turning to the brighter side. Doctor Jones
said WVU would be making significant new
efforts to “tell its story better” as to the quality
of its programs and graduates, and increased
retention of physicians in West Virginia. The
WVU School of Medicine was re-accredited in
March for another four years, with an interim
report set for 1985 a possible basis for a request
for a further accreditation extension.
The Liaison Committee, chaired by James L.
Bryant. M. D., of Clarksburg, commended Doc-
tor Jones for authorship of a special article,
“Financing of the West Virginia University
School of Medicine,” printed in the November.
1982, issue of The Journal.
‘Selected’ Providers Suggested
By Health Task Force
Number one on a list of nine priority recom-
mendations by a Health Cost Containment Task
Force calls for legislation to create a state regula-
tory commission with authority to limit amounts
hospitals charge patients.
Recommendation No. 2 proposes that hospitals
and medical services provided hy state funds be
expended pursuant to “State procedures that pro-
vide a more cost-effective delivery of hospital and
medical services.”
In elaborating on the second recommendation,
the final report by the Task Force — set up by
Governor Rockefeller in September. 1981 — pro-
vides some interesting reading. It says the
Review A Book
The following books have been received hy the
Headquarters Office of the State Medical Associa-
tion. Medical readers interested in reviewing any
of these volumes should address their requests to
Editor. The West Virginia Medical Journal. Post
Office Box 1031. Charleston 25324. We shall be
happy to send the hooks to you. and you may
keep them for your personal libraries after sub-
mitting to The Journal a review for publication.
Current Obstetric and Gynecologic Diagnosis
and Treatment , 4th Edition, edited by Ralph
C. Benson, M. D. 1,038 pages. Price $25.
Lange Medical Publications, Los Altos. Cali-
fornia 94022. 1982.
Stand Tall! — The Informed IV Oman’s Guide
to Preventing Osteoporosis, by Morris Notelovitz,
M. D., and Marsha Ware. 208 pages. Price
$12.95. Triad Publishing Company. Inc., P. 0.
Box 13096. Gainesville, Florida 32604. 1982.
Basic and Clinical Pharmacology, by Bertram
G. Katzung, M. D.. Ph.D. 815 pages. Price
$23.50. Lange Medical Publications, Los Altos,
California 94022. 1982.
20
The West Virginia Medical Journal
recommendation addresses the fact “that the
State is contributing to the high cost of health
care by permitting the free selection of hospitals
by persons whose hospital and medical services
are paid by the State." Here is further material
from the report:
“This recommendation could be implemented
by having the State select hospitals and medical
providers that provide the most cost-effective
services and authorizing payment for those ser-
vices not to exceed the State-approved rate.
“For example, in areas of the State with two
or more hospitals, the State could select the
hospital providing the most cost-effective service
and pay only the amount that hospital might
charge, regardless of where the area residents
might receive their services.
“If payments to hospitals and medical pro-
viders by the West Virginia Public Employees
Insurance Board, the Welfare Department, the
Workmen's Compensation Fund and all other
State-funded health payment programs were
made utilizing the rates of the most cost-effective
provider (s) in the area where the patient resides,
then a substantial saving would be made by the
State.
“In addition, such a program would stimulate
competition among providers to deliver the same
quality service at the least cost.”
The Task Force came up with 50 recommenda-
tions in all in the report made to the Governor
and the Legislature shortly before December 1.
Houston Doctor Named
WVU Medical Dean
Dr. Richard A. DeVaul, Associate Dean
of the University of Texas Medical School
at Houston, has been named Dean of the
West Virginia University School of Medicine,
it was learned as The Journal went to press.
Doctor DeVaul will assume his new posi-
tion in the spring, said Dr. John E. Jones,
WVU V ice President for Health Sciences.
Doctor DeVaul, 42. a native of Ames, Iowa,
specializes in psychiatry. He received his
M. D. degree from the Llniversity of
Rochester, and did his psychiatric residency
at Johns Hopkins University.
Doctor Jones said Doctor DeVaul “is a
man of outstanding credentials.
Doctor DeVaul will succeed Dr. Robert H.
Waldman. who was named Interim Dean
after Doctor Jones was promoted to his cur-
rent job last April.
At this writing, what bills for legislative con-
sideration might be generated by the recommen-
dations was not known, but a bill or bills to
establish a hospital rate review and rate-setting
commission seemed certain.
Similar legislation was tabled on the Senate
floor in 1982, and not considered at the commit-
tee or other levels in the House.
Charleston Pediatrician
Receives Award
Charleston pediatrician Henrietta Marquis,
M. D ., has become one of a handful of state resi-
dents to be honored as a Distinguished West
Virginian.
She received the award on December 8 from
Governor John D. Rockefeller IV during a sur-
prise ceremony in Charleston at the Capitol
Building on her 75th birthday.
Doctor Marquis specializes in child behavioral
problems. She has practiced in Richwood,
Beckley and Charleston during her career.
The award was created by Governor Rocke-
feller a few years ago. He praised Doctor
Marquis for her many years of service to
children in both the public and private sectors.
A native of Philadelphia, she moved to Rich-
wood in 1935. In 1977, at the age of 70, she
accepted a fellowship in child psychiatry at
WVU Charleston Division. After studying for
three years, she re-entered private practice. She
also is a consultant for the adolescent unit of
Lakin State Hospital.
Doctor Marquis received her undergraduate
degree from Cornell University and her M. D.
from the University of Pennsylvania.
She said she was overwhelmed by the award.
CME Program At Marshall
Gets Accreditation
The Accreditation Council for Continuing
Medical Education (ACCME) has granted four-
year accreditation to the Marshall University
School of Medicine.
Charles W. Jones, Ph.D., the school’s Director
of Continuing Medical Education, said the coun-
cil looks at the administration, financial stability
and educational integrity of programs, which can
be accredited for periods of one to six years.
Doctor Jones said the four-year period is
standard.
“Accreditation by the ACCME indicates to
the consumer that some national agency has re-
January, 1983, Vol. 79, No. 1
21
viewed the program and given its assurance that
we know how to evaluate continuing medical
education offerings and are able to screen them
for quality,” he added.
In the past year, the school’s continuing medi-
cal education program has served health pro-
fessionals from 41 West Virginia counties and
22 other states.
As a new medical school, Marshall previously
had had a two-year provisional accreditation.
State Funds Needed To Keep
Air Rescue Program
State funds totalling $3.73 million in 1983
are being sought for the full implementation of
an air medical rescue program which was started
on an experimental basis last July.
The West Virginia State Police MEDEVAC
project, conducted in 26 counties during the pilot
program, expires, along with its funding, this
month.
The program was put together jointly by the
West Virginia Department of Public Safety and
the Office of Emergency Medical Services in the
State Health Department. The two departments
now are enlisting the aid of the medical com-
munity in securing the needed state money.
The program provides rapid transfer of criti-
cal patients from general care medical facilities
to specialty care centers. Currently, the State
Police Aviation Division has two Bell jet heli-
copters which are manned by three pilots, hut
missions are limited to daylight hours and mini-
mum acceptable weather conditions.
27 Missions Completed
“To date there have been a total of 49 requests
for this air support link to the Emergency
Medical Service System, and 27 missions have
been completed,” said Samuel W. Channell,
Associate Director of the Office of Emergency
Medical Services. “We are finding that there is
indeed a real need for this service, especially
for critical patients in our more rural general
hospitals.”
In order to serve the entire state, the needs
include: sufficient funds for the acquisition of
two larger, twin-engine, all-weather helicopters;
necessary ground support; and six State Police
paramedics and six additional State Police
pilots.
State Police Chief Fred Donohoe is scheduled
to talk to physicians about the MEDEVAC pro-
gram on Saturday, January 22, during the 16th
Mid-Winter Clinical Conference in Charleston.
Medical Meetings
Jan. 10-12 — Am. Society for Laser Medicine & Sur-
gery, New Orleans.
Jan. 20-22 — Neurosurgical Societies of the Virginias,
Hot Springs, VA.
Jan. 21-23 — 16th Mid-Winter Clinical Conference,
Charleston.
Jan. 29-Feb. 3 — Am. College of Allergists, New Or-
leans.
Feb. 8-12 — Am. College of Emergency Physicians,
Surgery/Trauma, Detroit.
Feb. 11-13 — Biomedical Topics in Psychiatry (Medi-
cal College of VA), Hot Springs, VA.
Feb. 18-20 — Regional CME Meeting, Am. College of
Physicians, Alexandria, VA.
March 4-6 — Am. Medical Student Assoc., Cleevland.
March 10-15 — Am. Academy of Orthopedic Sur-
geons, Anaheim, CA.
March 20-24 — Am. College of Cardiology, New Or-
leans.
March 25-26 — Infection Control Workshop (Monon-
gahela General Hospital, WVU School of Medi-
cine), Morgantown.
April 15-17 — WV Chapter, AAFP, Morgantown.
April 17-21 — Am. Urological Assoc., Las Vegas.
April 17-22 — Operative Treatment of Fractures &
Nonunions (Johns Hopkins University), Hot
Springs, VA.
April 18-22 — Am. Roentgen Ray Society, Atlanta.
April 24-28 — Am. Assoc, of Neurological Surgeons,
Washington, D. C.
May 4-7 — WV Chapter, Am. College of Surgeons,
White Sulphur Springs.
May 8-12 — Am. College of Obstetricians & Gyne-
cologists, Atlanta.
May 13-14 — Topics in Cardiovascular Diseases (Am.
Heart Assoc.), Baltimore.
June 19-23 — Annual Meeting of AMA House, Chi-
cago.
Aug. 25-27 — 116th Annual Meeting, W. Va. State
Medical Assn., White Sulphur Springs.
Sept. 29-Oct. 2 — Am. Society of Internal Medicine,
San Francisco.
Oct. 9-14 — Am. College of Surgeons, Atlanta.
22
The West Virginia Medical Journal
IF YOU LOOKED AT THE NEW
1983 SAAB SEDAN THE WAY WE DO,
YOU’D CALL IT BEAUTIFUL, TOO.
Just look at the things that really matter.
For example, the new Saab’s backseat folds down to provide 53 cubic
feet of cargo space— more than any other sedan in America.
The 1983 Saab’s fuel-injected engine gives you the muscle of 6 or 8
cylinders, but does it with just 4.
And because the Saab has front-wheel drive, you experience superior
handling and stability, even during inclement weather.
And the list goes on.
If, however, you’re still not convinced that the new Saab Sedan is one
of the most beautiful cars in the world,
you’ll simply have to come by and take
a test drive. THE MOST INTELLIGENT CAR
And see for yourself. EVER BUILT.
WVU Medical Center
—News-
Compiled from material furnished by the Medical Center
News Service, Morgantown, W. Va.
Prehistoric Gene Works
‘Too Well’ Today
Diabetes is often caused by a “thrifty” gene
that in prehistoric times may have helped people
survive but now tends to make them obese and
subject to heart attacks.
Two WVU researchers, Drs. Margaret J.
Albrink and Irma H. Ullrich, are conducting
studies to determine the best kind of diet to
combat the effects of this misguided gene.
“Diabetes is very strongly genetically de-
termined,” Doctor Albrink said. “Yet it is very
common, especially the adult-onset variety or
Type II. To be both common and genetic, it
must have had survival value in past ages.
“The theory is that in those times food was
scarce and a person might have to go for days
without a meal. There would be survival value
in having this thrifty gene to enable you not
to spend too much energy, but to conserve it.
Result Obesity
“But when a creature who is genetically good
at conserving energy is suddenly and regularly
fed a lot, the result is obesity and the ailments
that often go with it, including diabetes,” she
said.
Doctor Albrink, who is President of the West
Virginia Affiliate of the American Diabetes As-
sociation, said one in every 20 Americans is
believed to have diabetes, and that half of the
cases are undiagnosed.
“Almost all individuals with undiagnosed
diabetes are overweight adults with non-insulin-
dependent or Type II diabetes,” she said.
“Diabetics are twice as prone to heart disease
and stroke, and the disease, with its complica-
tions, is the third leading cause of death by
disease in this country.”
Doctor Ullrich noted that while Type-I
“juvenile” diabetes requires insulin injections or
pills to lower blood sugar, Type II diabetics
xii
“may actually be made worse by insulin treat-
ment in some cases.”
“The reason is that insulin is a fattening
hormone, and weight loss is what many of these
patients urgently need. ' she said.
In addition to the dietary studies being con-
ducted by Doctors Albrink and Ullrich, WVU
Medical Center researchers are working with
other phases of diabetes. One of the most im-
portant involves gluconeogenesis, or how the
body produces its own blood sugar.
Doctor Albrink said that more than a dozen
Diabetes Association chapters around West Vir-
ginia observed Diabetes Month in November as
part of a national observance. Runathons,
bikathons and other fund-raising activities were
held, with most of the money to be used for
research and for patient and public education
about diabetes, she said.
Dr. Stephen C. Rector, resident in medicine, and
nurse Leah Heimbach examine an “accident victim”
during the recent advanced life support trauma
course at WVU Medical Center. The course, de-
signed to teach emergency life-saving skills, was
sponsored by the West Virginia Chapter of the
American College of Surgeons. Persons portraying
patients were made up by students from the WVU
Department of Art.
The West Virginia Medical Journal
New Harmarville program helps patients
control and live with pain.
Harmarville Rehabilitation Center
has assigned a special staff and 20-
bed unit for the exclusive treatment
of pain.
This program is achieving some
dramatic results, particularly with
back- and neck-injured patients. Over
90% of all pain program participants
have shown improved physical func-
tioning. For those patients whose
goal was to return to work, over 50%
achieved this goal. An additional 5%
of our former patients are under-
taking vocational training in prepara-
tion for employment.
Each pain patient is treated both
in a group and individually, and the
patient’s family is deeply involved
throughout the program. Treatment
involves physical therapy, biofeed-
back and relaxation training, educa-
tion and counseling, and vocational
programming. Most important, our
J*
Harmarville Rehabilitation Center, P.O. Box
Other special
Harmarville programs:
• Neuro-spinal program for the
rehabilitation of quadriplegics
and paraplegics.
• Head injury program for
cognitive retraining of brain-
injured patients.
• Claims Assessment for Rehabil-
itation Evaluation and Services
(CARES) for returning injured
workers to maximum level
of employment.
patients are taken off of all addicting
drugs for pain.
For more information on Harmar-
ville... its pain program and admission
procedures, call John F. Delaney,
M.D. or Mary Anne Murphy, Ph.D.
at 781-5700.
11460, Guys Run Road, Pittsburgh, PA 15238
Third-Party News, Views
and Program Concerns
AMA Complains About Proposed
Medicare Regulations
The American Medical Association recently
urged Richard Schweiker, Secretary of the U. S.
Department of Health and Human Services, to
give his personal attention to proposed regula-
tions that would alter Medicare reimbursement
systems for physicians and interfere with con-
tractual relationships between institutional pro-
viders and physicians. In a letter to the Secre-
tary, AMA Executive Vice President James H.
Sammons, M. D., said “many elements of the
proposal are arbitrary and outside of the author-
izing statute.”
The regulations, proposed by the Health Care
Financing Administration (HCFA) to imple-
ment Section 1887 of the Social Security Act,
would establish criteria and maximum limits on
reimbursement for physicians’ services furnished
to Medicare beneficiaries by “provider-based”
physicians. The letter to Schweiker included the
AMA’s November 5 statement to HCFA calling
for withdrawal of the proposed rules.
Statute Authorizations
The statute authorizes regulations to dis-
tinguish between physician services provided to
individual patients and those services that are
provided for the “general benefit . . . (of) pa-
tients in a hospital or a skilled nursing facility”
for the purpose of allocating the cost of physi-
cian services between Medicare Part A and Part
B. It also authorizes establishment of “reason-
able compensation equivalents” that are to be
applied as the maximum Medicare reimburse-
ment for services furnished for the general bene-
fit of the patient population.
In its statement, the AMA said the proposed
regulations broaden the statute by extending
reasonable compensation equivalents to Part B,
whereas the law states that this system is to
apply to professional services rendered for the
general benefit of patients (Part A). The AMA
said the rule would set limitations on anesthesi-
ology and radiology services that are not author-
xiv
ized by law and would inappropriately deny
Medicare reimbursement under Part B for clini-
cal pathology services.
Compensation Fund Stresses
Consultation Policy
Workmen’s Compensation Commissioner
Gretchen 0. Fewis has called new attention to
the Compensation Fund’s policy regarding con-
sultations requested by physicians. The policy
first was set forth in The Journal in October,
1980.
The Fund continues to feel that the policy
facilitates more timely medical care for injured
workers; eliminates administrative paperwork
and delay in the Fund as well as in doctors’
offices; and permits, from the agency’s view-
point, better claims management.
The policy, set forth below, did not change
a procedure stipulating that prior authorization
be requested for a change of treating physician;
treatment by other than the physician of record,
and hospitalization /surgical intervention.
Here, again, is the material provided earlier:
NEW CONSUFTATION POLICY
Effective November 1, 1980
If, in the opinion of the treating phy-
sician of record, a consultation (examina-
tion only ) is deemed advisable in relation
to the compensable injury, the treating phy-
sician may, without prior authorization,
arrange the consultation, provided the con-
sulting physician is located within 100 miles
of the claimant’s residence. However, the
treating physician, upon arranging the con-
sultation, must immediately notify the fund
of the referral by narrative report outlining
the claimant’s condition and the reason a
consultation is desired. It also is necessary
that the consultant provide the Fund with a
narrative report of the findings and recom-
mendations.
The West Virginia Medical Journal
The Eye and Ear Clinic of Charleston, Inc.
(A Thirty-Five-Bed Accredited Hospital)
Charleston, West Virginia 25301
Phone: (304)-343-4371
Toll Free: 1-800-642-3049
OPHTHALMOLOGY
Milton J. Lilly, Jr., M.D.
Robert E. O’Connor, M.D.
Moseley H. Winkler, M.D.
Samuel A. Strickland, M.D.
E.E.N.T.
John A. B. Holt, M.D.
OTOLARYNGOLOGY-
HEAD AND NECK
SURGERY
Romeo Y. Lim, M.D.
Nabil A. Ragheb, M. D.
R. Austin Wallace, M. D.
RETINAL SURGERY
HEAD AND
NECK SURGERY
OPHTHALMIC PLASTIC SURGERY MAXILLO-FACIAL PLASTIC SURGERY
FLUORESCEIN ANGIOGRAPHY RECONSTRUCTIVE SURGERY
ARGON LASER PHOTOCOAGULATION ENDOSCOPY
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56TH & NOYES AVE., S.E.
CHARLESTON, W. VA. 25304
925-4756
MEDICAL STAFF
ADULT PSYCHIATRY
Miroslav Kovacevich, M. D. 925-0693
Charles C. Weise, M. D. 925-2159
Thomas S. Knapp, M. D. 925-3554
Pablo M. Pauig, M. D. 343-8843
Ralph S. Smith, M. D. 925-0349
Lee L. Neilan, M. D. 925-0349
Edmund C. Settle, Jr., M. D. 925-6914
Gina Puzzuoli, M. D. 925-6914
John P. MacCallum, M. D. 925-6966
CHILD PSYCHIATRY
Henrietta L. Marquis, M. D. 925-3160
Pablo M. Pauig, M. D. 343-8843
Ralph S. Smith, M. D. 925-0349
John P. MacCallum, M. D. 925-6966
Psychiatric treatment for the emotionally
disturbed children ages 5 to 13 now avail-
able in new children’s pavilion. Separation
maintained from adult psychiatric care
unit. Each program offers:
• Crisis Intervention
• Group Therapy
• Psychotherapy
• Activities & Recreational Therapies
• Skilled Attention to Family, Marital, and
Individual Emotional Problems
• Special Care for the Acutely Disturbed
Patient
• Staffed by Qualified Psychiatrists and
Medical Consultants
• Schooling Provided on Children’s Pa-
vilion
• Serving the Community for Over 25
Years
January, 1983. Vol. 79, No. 1
xv
Obituaries
CLARK K. SLEETH, M. D.
Dr. Clark K. Sleeth, former Dean of the West
Virginia University School of Medicine and a
key figure in its development and growth, died
on November 30 in a Morgantown hospital. He
was 69.
Doctor Sleeth had been a member of the
University faculty for more than 40 years. From
1961 until 1970, he served as Dean of the Medi-
cal School, which awarded its first doctorates in
1962.
After stepping down as Dean, Doctor Sleeth
organized the University's Department of Family
Practice in the early 1970s, and served as its
Acting Chairman until 1973.
Doctor Sleeth, a member of the State Medical
Association’s Committee on Medical Scholar-
ships since 1960, coordinated the scheduling of
the Committee’s annual interviews of beginning
medical students for West Virginia medical
school scholarships awarded each year by the
Association. His service to the Committee con-
tinued beyond retirement in 1978 and included
the 1982 meeting of the Committee last summer.
Born in Logansport, Marion County, Doctor
Sleeth was graduated from WVU, and received
his M. D. degree in 1938 from the University
of Chicago. He took his internship and resi-
dency at the Henry Ford Hospital in Detroit.
He was a student of, and later a co-worker
with, the late Dr. Edward J. Van Uiere, con-
sidered the father of the four-year School of
Medicine. He succeeded Doctor Van Liere as
Dean.
During Doctor Sleeth’s tenure, the School's
graduating classes more than doubled, and it
joined tbe ranks of leading centers for medical
education and research.
As a physiologist and pathologist, Doctor
Sleeth was author or co-author of some three
dozen research papers.
A Professor Emeritus since his retirement,
Doctor Sleeth continued working on several pro-
jects, including an updated history of the WVU
Medical School faculty.
He was an honorary member of the Monongalia
County Medical Society, West Virginia State
Medical Association, and American Medical As-
sociation.
Doctor Sleeth was President of the Monongalia
County Medical Society in 1951, and Eirst Vice
President of the State Medical Association in
1952.
Survivors include the widow; three daughters,
Mrs. Hubert A. Shaffer, Jr., of Charlottesville,
Virginia, Mrs. Jerry L. Creamer of Dallas and
Mrs. David M. Fulton of Charleston, South
Carolina; one sister, Mrs. Louis Hagan of
Wheeling, and one brother, Charles R. Sleeth of
Madison, New Jersy.
♦f W #
BERNARD ZIMMERMANN, M. D.
Dr. Bernard Zimmermann, who organized and
for 13 years headed the Department of Surgery
at the West Virginia Efniversity School of Medi-
cine, died on December 4 in a Morgantown
hospital. He was 61.
Doctor Zimmermann was the first person to
be named chairman of a clinical department in
preparation for the 1960 opening of LIniversity
Hospital, which marked the actual beginning of
WVU's four-year School of Medicine. He then
was Professor of Surgery at the University of
Minnesota Medical School.
In 1971, he was elected President of the
Halsted Society, named for the father of modern
surgical techniques and including some 150
leading educators in surgery and allied branches.
In 1973, Doctor Zimmermann resigned as
Chairman of Surgery and returned to full-time
teaching, research and operative surgery. The
following year, an international group that in-
cluded several of his former chief residents
organized the Bernard Zimmermann Surgical
Societv. which sponsored lectures and prizes for
outstanding students.
Doctor Zimmermann. a native of St. Paul,
Minnesota, received both his undergraduate and
M. D. I 1945 ) degrees from Harvard University.
He interned at Boston City Hospital and, in
1953, earned a Ph.D. degree ( Doctor of
Philosophy in Surgery ' from the University of
Minnesota.
A Navy veteran, he also was a member of
the American Surgical Association. American
College of Surgeons, National Society for Medi-
cal Research. Monongahela County Medical
Society, and West Virginia State Medical As-
sociation.
In 1981, a portrait in tribute to Doctor
Zimmermann was placed in tbe Medical Center.
Survivors include the widow; two sons,
Bernard Zimmermann III of Swansea, Massa-
chusetts, and Andrew Zimmermann of Somer-
ville, Massachusetts; a sister, Mrs. Walter
Limbach of Pittsburgh; and a cousin, Charlotte
Nelson Smith of St. Paul.
xvi
The West Virginia Medical Journal
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P.O. Box 3186, Charleston, WV 25332
Telephone: 1-304-347-0708
County Societies
CENTRAL WEST VIRGINIA
Dr. Harry Shannon of Parkersburg, President
of the State Medical Association, addressed the
meeting of the Central West Virginia Medical
Society on October 28.
The meeting was held at the Bicentennial
Motel in Buckhannon.
Other guests include Dr. Tom Stahly, a new
radiologist from Summersville; Charles R. Lewis
of Charleston, Executive Secretary of the State
Medical Association, and Mrs. Richard S.
(Linda) Kerr of Morgantown, President of the
Auxiliary to the State Medical Association.
It was reported that the Cowen water supply
has been fluoridated.
The Society elected new officers. — Joseph B.
Reed, M. D., Secretary-Treasurer.
» • »
WESTERN
The Western Medical Society met on Novem-
ber 9 in Spencer at Roane General Hospital.
The guest speaker was Dr. Harry Shannon of
Parkersburg, President of the State Medical As-
sociation.
Doctor Shannon gave a very interesting talk
about involvement of individual members of the
Medical Society in health care, and also dis-
cussed the present status of malpractice insurance
and cases in West Virginia in comparison with
other states. A question-and-answer period fol-
lowed.
New officers were elected. — Ali H. Morad,
M. D., Secretary-Treasurer.
• * *
McDowell
The McDowell County Medical Society met
on November 10 at Stevens Clinic Hospital in
Welch.
Following a pot-luck dinner arranged by the
Auxiliary, there was a short presentation on
domestic violence presented by Norman Googel
and Associates from McDowell County.
It was reported that a poll of the Society was
favorable for the support of an extended care
facility in the County. The request for support
had come from the Imperial Construction Com-
pany.
New officers were elected. — Muthusami
Kuppusami, M. D., Secretary.
* * #
BOONE
The Boone County Medical Society met on
November 30 at the Boone County Health
Center, a new nursing home.
Officers for 1983 were elected, and three new
members practicing in Madison were admitted.
The Society has chosen the second Tuesday
of each month for its meeting date and con-
tinuing medical education. — Manuel T. Uy,
M. D., Secretary-Treasurer.
Over 40 Practice Opportunities
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West Virginia Department of Health
1800 Washington Street, East
Charleston, West Virginia 25305
Phone: 348-0575
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xx
The West Virginia Medical Journal
The West Virginia Hedical Journal
Vol. 79, No. 2 February, 1983
Metastatic Cancer Of Unknown Origin: Ohio Valley
Medical Center Experience
GURIJALA N. REDDY, M. D.
Department of Radiation Oncology, Ohio Valley
Medical Center, Inc., Wheeling, West Virginia; and
Clinical Assistant Professor of Radiology, West Virginia
University School of Medicine
One hundred and fifty-one patients with
metastatic carcinoma from an unknown primary
site were treated from 1969 to 1980 at Ohio
l' alley Medical Center [OVMC), Inc., Wheeling,
West Virginia. Diagnosis, survival and prognosis
of these patients are discussed.
ATetastatic cancer of unknown origin is more
frequently encountered in clinical practice
than it was once believed. It constitutes 10 to
15 per cent of all cancer cases, and is a diag-
nostic and therapeutic challenge. Many articles
have been published on the subject with reference
to diagnosis and treatment, but the emphasis on
investigating a patient with an occult primary
cancer site is shifting from an aggressive to a
conservative approach. It is evident from the
literature that all types of metastatic cancer
(different sites and histological varieties) with
undetermined primary sites are not the same.
For example, metastatic squamous carcinoma in
the upper neck nodes should be worked up and
treated differently from squamous or adenocarci-
noma in the supraclavicular area or in the bone.
The former usuallv has a better prognosis than
the latter. Such patient material from OVMC
is reviewed here with reference to survival, and
a plea is made for judicious use of diagnostic
methods. Because lymphomas constitute a dif-
ferent entity, they are excluded from this review.
Materials and Methods
OVMC Tumor Registry was searched for
patients with metastatic carcinoma at single or
multiple sites whose primary site could not be
determined. There were 151 patients from 1969
to 1980 with histologically-proven diagnosis. In
only five of these patients was histological
diagnosis made at autopsy. Of the 151 patients.
89 were males and 62 were females. Ages ranged
from 34 to 90 years, with a majority of patients
being 60 or older. There were an additional 51
patients who would have been included in this
study except for a lack of histological confirma-
tion of diagnosis.
The presenting sites of metastatic cancer are
listed in Table 1. The most common single site
of mestastases was the lymph nodes, followed
by the bone. Adenocarcinoma and undifferenti-
ated carcinoma were the most common cell types
as shown in Table 2. All patients bad complete
TABLE 1
Presenting Site of Metastatic Cancer
Site
No. of Patients
Lymph Nodes
38
Bone
25
Abdomen
19
Liver
17
Brain
8
Lung
6
Generalized 0
10
Other
28
TOTAL
151
° More than one site at diagnosis
February, 1983, Vol. 79, No. 2
23
TABLE 2
Histology
Type
No. of Patients
Squamous
25
Adeno Ca
44
Undiff. Ca
42
Unspecified Ca
31
Cytology
3
Other
6
TOTAL
151
histories recorded and physicial examinations
performed. Their metastatic workups included
a wide variety of hematological, biochemical,
roentgenographic, isotopic, invasive and non-
invasive x-ray studies as well as endoscopic
examinations. In only a few of the patients
could the primary site be determined.
Survival figures are rather grim; however,
they are consistent with other published reports.
Thirty per cent of these patients died within
one month, and 80 per cent died within one year
after the diagnosis was made. Only 20 per cent
survived for one year or longer. The majority
of the latter group were squamous carcinomas
metastatic to upper neck nodes. These patients
usually have a better prognosis than those with
other metastases in other sites. Five patients
were lost to follow-up and were counted as dead
of cancer. Thirteen patients are alive at the time
of this report.
Autopsy was performed on 13 patients. Of
these, the primary site was found in only six —
two lung and one each pancreas, ovary, kidney
and rectum. In the remaining seven cases, the
primary site of malignancy could not be de-
termined.
Fifty-one other patients, 28 males and 23
females, with clinical and x-ray diagnosis but
without histological confirmation, had equally
poor or worse survival. Ninety per cent of these
patients died within one year from the time of
clinical diagnosis.
Adequate testing and appropriate treatment
did not seem to influence the survival of these
TABLE 3
Mortality
1 Month
1 2 Months
No. of Patients
No. of Patients
With Histology
45/151
30%
121/151 80%
Without Histology
29/51
58%
46/ 51 90%
TABLE 4
Survival — Review of Literature
Total No.
Patients
%
Living
Time After
Dx - Month
Moertel et al 4
150
10
14
Stewart et alA
87
12
12
Richardson et al. 2
86
12
12
Reddy 2
151
20
12
1 Adeno Ca only
2 All cell types (including neck node metastases)
patients. No attempt is made to analyze the in-
vestigations in detail.
Discussion
Many reports in the literature reveal that the
survival of the patients with metastatic carci-
noma whose primary site is unknown is poor
(Table 4). Moertel et al. 1 from the Mayo Clinic
reported 10-per cent survival at 14 months in
150 patients with metastatic adenocarcinoma of
unknown origin treated with various chemo-
therapeutic agents. Richardson and Parker 2 re-
ported 86 patients with unknown primary
malignancy: 50 per cent died within three months
and, by one year, 12 per cent remained alive.
Nystrom et al . 3 reported 266 patients with
metastatic cancer from an occult primary site.
An excellent review of diagnostic testing in this
study revealed that only 8/218 (3.6 per cent)
upper gastrointestinal tract contrast roentgeno-
grams, 9/198 (4.5 per cent) full column barium
enema examinations, and 5/187 (2.6 per cent)
intravenous pyelograms were true positive re-
sults. This is a very low yield rate indeed. The
authors also had many false positive results, and
advocate use of these tests with specific organ
dysfunction or clinical suspicion of abnormality.
Stewart et al. 4 from Sydney, Australia, re-
ported 87 patients with malignancy from un-
known primary site. The primary site could be
determined in only eight patients after extensive
workup. Median survival was 13 to 14 weeks.
Only 12 per cent were alive at 12 months (esti-
mated from graph ) . Because of the low yield
rate and little influence on survival, they recom-
mend fewer investigations as warranted by
the individual patient’s situation.
Steckel and Kagan 5 reported from the Uni-
versity of California, Los Angeles 253 patients
with unknown primary site of malignancy
initially. In 34 autopsies no primary site could
be found in 20 cases and, of the remaining 14,
seven patients had lung cancer. They com-
24
The West Virginia Medical Journal
merited that “long and arduous diagnostic ex-
aminations may he pointless academic exercise.”
Workup Not Rewarding
Based on the present survival figures and re-
view of the literature, it is evident that extensive
diagnostic workup is not likely to be rewarding
in locating the primary cancer site. Even if it
is located it will have little influence on the
treatment (with very few exceptions) and on
prolonging the survival of the patients. When
approximately 90 per cent of these patients are
expected to die of cancer within one year, putting
them through expensive, time-consuming and
uncomfortable diagnostic tests may not be justi-
fied.
By definition, metastatic disease in various
sites, except in some neck nodes, is a stage IV
disease which carries poor prognosis no matter
where the primary is located. Metastasis is
usually by hematogenous and, occasionally,
lvmphatic spread, suggesting generalized disease
even though metastasis to only one site may be
obvious at initial diagnosis. The majority of
these patients are treatable by surgery, radiation
therapy or chemotherapy, but are incurable.
By no means should any test that is likely
to improve the patient’s comfort and survival be
withheld on the pretext of poor prognosis; how-
ever, blind and frantic search for primary loca-
tion of cancer in every patient is discouraged.
Patients do deserve special attention and ade-
quate treatment, even for palliation, which should
be highly individualized because of a wide
variety of histological types and locations at
initial diagnosis.
References
1. Moertel CG, Reitemeier RJ, Schutt AJ, Hahn RG:
Treatment of the patient with adenocarcinoma of un-
known origin. Cancer 1972; 30:1469-72.
2. Richardson RG, Parker RG: Metastases from un-
detected primary cancers. West J Med 1975; 123:337-
339.
3. Nystrom JS, Weiner JM, Wolf RM, Bateman JR,
Viola MV : Identifying the primary site in metastatic
cancer of unknown origin. JAMA 1979; 241:381-83.
4. Stewart JF. Tattersall MHN, Woods RL, Fox RM:
Unknown primary adenocarcinoma: Incidence of over-
investigation and natural history. Br Med J 1979;
1(6177): 1530-1533.
5. Steckel RJ, Kagan AR: Diagnostic persistence in
working up metastatic cancer with an unknown primary
site. Radiology 1980; 134:367-369.
To be engaged in opposing wrong affords but a slender guarantee for
being right.
— William Gladstone
February. 1983, Vol. 79, No. 2
25
Epikeratophakia : A New Treatment For Corneal
Irregularity And Keratoconus
THEODORE P. WERBLIN, M. D„ Ph.D.
The Blaydes Foundation , Bluefield, West Virginia
The technique of epikeratophakia has been
modified to treat corneal surface irregularity
I astigmatism ) and keratoconus. A lamellar cor-
neal graft is sutured tightly in place atop the
intact recipient cornea. The graft produces a
flattening of the cornea and facilitates contact
lens or spectacle correction of vision.
A case report of a keratoconus patient whose
preoperative irregular astigmatism was elimi-
nated and whose myopia was reduced 12 diopters
is presented here. This procedure has much less
morbidity than penetrating keratoplasty which
is the usual treatment for advanced keratoconus.
To date, corneal graft rejection has not been
encountered with this procedure.
\ interior keratoconus is a noninflammatory
■T*- axial ectasia of the cornea. It becomes
recognizable at puberty and can progress
relatively quickly or slowly with stabilization.
Protrusion of the apex occurs because of thinning
of the cornea. Clinically, this can be recognized
by distortion of the curve of the lower lid caused
by the corneal cone with the eye in down gaze
(Munson’s sign). Focal disruption of Bowman’s
layer causes the epithelium to be irregular in
thickness and the basement membrane to be
abnormal. When Descemet’s membrane is
stretched beyond its elastic breaking point, acute
clouding of the cornea (bydrops) may occur.
This increase in corneal clouding results from
profound stromal edema.
Initial treatment includes the use of a hard
contact lens to correct vision. This eliminates
irregular corneal surface (astigmatism), but
eventually contact lens fitting becomes impos-
sible because this increasingly irregular corneal
surface does not allow the lens to stabilize. Many
cases of advanced keratoconus can be treated
surgically with either penetrating or lamellar
keratoplasty; however, penetrating keratoplasty
may be impossible with large cones that extend
to near the limbus. This form of surgery has
the continual risk of graft rejection and cataract
formation. Lamellar surgery is preferable be-
cause these risks are minimized or nonexistent.
Previous forms of lamellar keratoplasty were
extremely difficult because they required careful
lamellar dissection over the surface of the cone. 1
A new approach to the treatment of kerato-
conus has been developed by modifying the
technique of epikeratophakia, 2,3,4 a form of
lamellar refractive surgery. In this procedure,
donor corneal tissue is lathed in the shape of
a contact lens and sutured to the anterior surface
of the recipient cornea. Any optical function
which a contact lens can perform theoretically
can he served by these lamellar grafts. For
keratoconus, a piano lamellar graft ( parallel
surfaces ) is sutured tightly in place to flatten
the irregular corneal surface. The residual
refractive error can be handled with either con-
tact lenses or spectacles.
Case Report
A 33-year-old, white male had had poor vision
for many years. He was first seen at The Blaydes
Clinic in 1971, at which time he stated that the
doctors in the military sendee had diagnosed
keratoconus. His visual acuity was 20/50 OD
and 20 / 200 OS, and his keratometer readings
were 43.00 @ 180° x 41.30 @ 90° OD and
45.50 @ 180° x 42.00 @ 90° OS. Slit-lamp
evaluation showed some central thinning in the
right eye hut no breaks in Bowman’s membrane.
However, a definite corneal irregularity in the
left eye with a small amount of central corneal
opacification and thinning was revealed. The
cone was located in the infratemporal portion
of the cornea.
Figure 1. Preoperative appearance of the cornea.
The irregularity of the curve of the anterior corneal
surface and a small apical scar can be seen.
26
The West Virginia Medical Journal
The patient was informed that he might need
a corneal transplant in the future but was ad-
vised to try hard contact lenses for the time
being. The patient wore his contact lenses suc-
cessfully for 10 years.
In May, 1981. an ulceration was discovered on
the apex of the cone in his left eye. His visual
acuity with contact lenses was 20/25 OD and
20 300 OS. The patient was then advised not
to wear his contact lenses. He was treated
medically, and the ulceration improved. The
epikeratophakia procedure was explained to him
when he was seen in June. 1981, because of his
intolerance to contact lenses.
The patient's workup revealed the following
findings: Vision (without correction) 20 80
OD. 20/300 OS; Vision (with spectacle correc-
tion ) 20 30 OD, 20 200 OS; Vision (with con-
tact lenses) 20 20 OD. 20/70 OS; Vision (with
contact lenses and pinhole) 20/20 OD. 20/25
OS; Pachometry (stromal thickness) .51 mm
OD. .43 mm OS and Tension 13 OD. 19 OS.
His A-Scan readings were 24.57 OD, 24.78 OS,
and his keratometry readings were 43.25 @
75 x 44.25 @ 165 OD and 65.75 @ 20° x
53.00 @ 110' OS. Minimal apical scarring of
the cornea was seen in the OS.
Graft Performed
The epikeratophakia lamellar graft was per-
formed on the left eye on August 13, 1981
(Figure 1). In this procedure the epithelium
was removed from the recipient cornea with
absolute alcohol. A small amount of epithelium
was left remaining in the periphery of the cornea.
The peripheral cornea was trephined to a depth
of 0.15 mm (8.0 mm in diameter), and the
inner edge of the trephine cut excised to create
a circular bed 0.5 mm wide and 0.15 mm deep.
Figure 2. Postoperative appearance of the lamellar
graft at three weeks. A somewhat hazy appearance
is characteristic of the early postoperative appear-
ance of these grafts.
The exposed corneal stroma allows the graft to
scar securely in place.
The lenticule ( diameter 8.25 mm) was sutured
to the recipient cornea ( 8.0-nmi-diameter bed)
using 20 multiple interrupted 10-0 nylon sutures.
The graft was sutured under sufficient tension
to flatten the central corneal cone. A piano
bandage soft contact lens was used to cover the
graft and protect the epithelium as it grows
across the graft. At the time of surgery, the
postoperative keratometry was 38.50 @ 55" x
43.75 @ 145°.
At three weeks, the corneal graft surface was
completely covered with epithelium, and the
bandage contact lens was removed. The donor
corneal graft measured 0.2 mm thick, and the
recipient measured 0.44 mm (Figure 2). All
sutures were removed by three months post-
operatively. At 13 weeks keratometry readings
were 43.62 @ 21 x 49.62 @ 105 . Visual
acuity was 20 200 without correction and 20/30
-1 with spectacle correction (-1.25 -3.50 x 120)
( Figure 3 ) .
Discussion
Penetrating keratoplasty is not always suc-
cessful in the treatment of keratoconus, particu-
larly in the case of extensive or displaced cones.
Penetrating grafts are always subject to immune
rejection. On the other hand, lamellar grafts,
although safer, have not had the potential for
producing 20 20 vision. 1 This is probably due
to the extensive dissection of the recipient cornea
and resultant interface scarring. In addition, the
lamellar dissection is technically very difficult.
Epikeratophakia is a new form of lamellar
refractive surgery which avoids this technical
complexity. In the epikeratophakia procedure,
the peripheral cornea is trephined to create a
Figure 3. Three-month appearance of graft. By
this time, all sutures have been removed and the
graft has become quite clear.
February, 1983, Vol. 79, No. 2
27
circular bed. This trephine mark allows the graft
to scar securely in place. The patient’s cornea
needs no other lamellar dissection. There is no
manipulation of the thinned area of the cone,
and the anterior chamber has no chance of being
penetrated.
The epikeratophakia technique has been modi-
fied to produce flattening of the keratoconus
cornea to facilitate contact lens or spectacle cor-
rection of vision. This is accomplished by sutur-
ing the piano lamellar graft tightly in place.
These lamellar grafts do not seem to undergo
immune rejection, and thus avoid this major
complication of penetrating grafts. In addition,
this technique has produced 20/20 visual acuity
in keratoconus patients. 4
Currently, keratoconus lamellar grafts are
lathed with no refractive power. It is feasible
that a microkeratome section could be used in
place of lathed tissue. This would simplify the
procedure. Donor tissue must be frozen in order
to be cut on the cryolathe. This kills the
keratocytes and makes the donor disk a non-
viable tissue. Microkeratome sectioning would
allow living tissue to be used. This may speed
the visual recovery of the recipient eye.
Improves Three Major Problems
The treatment of keratoconus with epiker-
atophakia grafts was designed to improve the
three major visual problems associated with this
condition: myopia, regular astigmatism and
irregular astigmatism. Postoperatively, the pa-
tient in this case study has shown less myopia
and cylinder compared to preoperative values,
and has lost the irregular astigmatism character-
istic of keratoconus. The residual astigmatism
and myopia also theoretically could be treated
with these lamellar grafts. Experimental ap-
proaches to these complex optical problems cur-
rently are under investigation.
Reference
1. Malbran E: Lamellar keratoplasty in kera-
toconus, in King JH, McTigue JN (eds): The Cornea-
World Congress, Washington, DC, Butterworth, 1965.
p 511.
2. Werblin TP, Kaufman HE: Epikeratophakia: The
surgical correction of aphakia. II. Preliminary results in
a non-human primate model. Curr Eye Res 1981; 1:131-
137.
3. Werblin TP, Kaufman HE, Friedlander MH,
Granet N: Epikeratophakia: The surgical correction of
aphakia. III. Preliminary results of a prospective clinical
trial. Arch Ophthalmol 1981; 11:1957-1960.
4. Kaufman HE, Werblin TP: Epikeratophakia: A
form of lamellar keratoplasty for the treatment of kera-
toconus. Submitted to Am J Ophthalmol.
28
The West Virginia Medical Journal
Tension Pneumothorax During Anesthesia*
STEPHEN T. PYLES, M. D.
Resident in Anesthesiology, University of Florida,
Gainesville
DAVID A. HAUGHT, M. D.
Huntington, West Virginia, Clinical Professor of
Surgery, Marshall University School of Medicine,
Huntington
ELMER T. VEGA, M. D.
Huntington, Clinical Associate Professor of Surgery,
and Coordinator, Section of Anesthesiology, MU School
of Medicine
EDUARDO A. RIVAS, M. D.
Huntington, Clinical Instructor in Surgery, MU School
of Medicine
Two cases of tension pneumothorax occurring
shortly after the induction of general anesthesia
are presented. Each complication was linked to
the improper use of an accessory anesthetic
ventilator valve known as the ventilator-mounted
switch valve.
'T'ension penumothorax directly attributable to
the improper attachment of the anesthesia
circuit to a directional valve on the ventilator
known as the “ventilator-mounted switch valve”
has been described. 1 This device (Figure 1),
however, still can be found on many anesthesia
ventilators, and continues to be causative in the
production of tension pneumothorax during
anesthesia.
Case One
A 68-year-old female was scheduled for repair
of a herniated lumbar disc. Her blood pressure
was 138 80 mmHg, pulse 82/minute and respi-
rations 16/minute. Anesthesia was induced using
sodium pentothal. Succinylcholine was given to
facilitate endotracheal intubation. An en-
dotracheal tube was placed without difficulty,
and breath sounds were found to be clear and
equal bilaterally. Vital signs remained stable
throughout the induction period. The patient
subsequently was turned to the prone position
on the operating table where her breath sounds
were checked again and found to be normal.
The ventilator tubing was then accidentally
connected to the ventilator-mounted switch
“This paper was written while Doctor Pyles was a
surgical resident at Marshall University School of Medi-
cine, Huntington, West Virginia. Reprint requests may
be directed to Doctor Pyles.
valve post usually occupied by a reservoir
bag. Tachycardia, hypotension, and subcutaneous
emphysema occurred within the minute. The
patient was immediately disconnected from the
ventilator, and a loud rush of air was heard
coming from the endotracheal tube. A chest
x-ray showed a large pneumothorax, mediastinal
shift, and subcutaneous emphysema I Figure 2).
Chest tubes were placed and recovery was un-
eventful.
Case Two
A 52-kilogram, 16-year-old female was sched-
uled for an appendectomy. On arrival in the
operating room she was afebrile, with a blood
pressure of 126 80 mmHg, a pulse of 84 per
minute and a respiratory rate of 14 per minute.
She had no history of medical problems. In-
duction of anesthesia was uneventful. D-tubo-
curarine pre-treatment was followed by sodium
pentothal 220 mg. and succinylcholine 80 mg.
An endotracheal tube was inserted with ease.
The breath sounds were clear and equal bilateral-
ly prior to connecting the patient to the venti-
lator.
Shortly after the initiation of mechanical
ventilation the surgeon complained that the blood
Figure 1. The ventilator-mounted switch valve
with arrows indicating the internal channels.
February, 1983, Vol. 79, No. 2
29
was dark. The chest was noted to be hyper-
inflated and motionless. The ventilator cycled
as usual without corresponding chest wall move-
ment. The endotracheal tube was disconnected
from the circuit and a large volume of air rushed
from the tube. One hundred-per cent oxygen was
given by manual-assisted ventilation. Lung
compliance was noted to be poor; however, vital
signs were satisfactory with a blood pressure of
100/60 and a pulse of 100-110 per minute.
Breath sounds were diminished on the right side.
A recovery room chest x-ray demonstrated a 30-
per cent penumothorax on the right. A chest
tube was placed and recovery was uneventful.
Discussion
In a study by Cooper et al., 2 19.5 per cent of
all anesthesia misadventures were categorized as
“ventilator/breathing circuit” problems.
Each patient presented developed a tension
pneumothorax secondary to the improper con-
nection of the anesthesia circuit to the ventilator-
mounted switch valve (Figures 3 and 4). The
Figure 2. Patient number one. Portable post-
induction chest x-ray in operating room. Note large
left tension pneumothorax with mediastinal shift.
ventilators continued to cycle without delivering
their volume to the patients and without audible
changes in their operation. The lungs were over-
distended to the point of rupture by anesthetic
gases flowing directly into a patient’s lungs
through a closed system. Inadvertent build-up
of pressure within the ainvay occurs when
there is a continuous flow of anesthetic gases
into the trachea with an obstruction to out-
flow. Modern anesthetic machines are capable
of delivering pressures in excess of 4000 cm
Hl'O directly to the trachea when a cuffed
endotracheal tube is in place. 3
A medical device alert was distributed by
Ohio Medical Products on December 8, 1981.
In their letter they state, “AFTER CAREFUL
REVIEW, WE STRONGLY URGE THAT THE
USE OF THESE VALVES BE DISCONTINUED
Figure 3. This photo demonstrates the ventilator
tubing improperly attached at the reservoir bag
port. Note that the stopcock is directed horizontally.
In this situation gas flows from the anesthesia ma-
chine, fills the ventilator tubing and is blocked by
the stopcock. Anesthetic gases continue to flow
into the patient’s lungs through a closed system,
resulting in pneumothorax. The ventilator cycles
normally, delivering its volume directly into the
room through the open port.
30
The West Virginia Medical Journal
Figure 4. The ventilator-mounted switch valve
shown with stopcock directed vertically. This posi-
tion allows manual ventilation without disconnect-
ing ventilator tubing. The vertical post is the bag
port, and the horizontal post is the ventilator tubing
port.
IMMEDIATELY AND THAT THESE VALVES
BE PROMPTLY REMOVED FROM THE
VENTILATORS AND DISPOSED OF IN A
PROPER MANNER. WE SUGGEST STRIKING
THE ENDS WITH A HEAVY OBJECT TO DE-
FORM. RENDERING THE VALVE INOPERA-
TIVE.”
Summary
Two cases of tension pneumothorax occurring
during anesthesia are presented. These compli-
cations could have been prevented if either the
ventilator-mounted switch valve had been used
correctly or the breath sounds had been recheck-
ed immediately after connecting the patient to
the ventilator.
The anesthesia ventilator-mounted switch
valve continues to be associated with anesthesia
morbidity, specifically tension pneumothorax.
The continued use of this device should be
seriously questioned. We recommend immediate
removal of the ventilator-mounted switch valve
from all anesthesia ventilator systems.
References
1. Sears BE, Bocas ND: Pneumothorax resulting from
a closed anesthesia port. Anesthesiology 1977; 47:311-
313.
2. Cooper JB, Newbower RS, Long CD, McPeek B:
Preventable anesthesia mishaps: A study of human fac-
tors. Anesthesiology 1978; 19:399-406.
3. Newton NI, Adams AP: Excessive airway pressure
during anesthesia. Plazards, effects, and prevention.
Anaesthesia 1978; 33:609-699.
February, 1983, Vol. 79, No. 2
31
From the Wesl Virginia University
Medical Center
Edited By
Irma II. Ullrich, M. D.
Associate Professor of Medicine
Relapsing Polychondritis
Case Presentation:
TIMOTHY COOLEY, M. D.
Resident in Medicine
Discussant:
ROXANN POWERS, M. D.
Assistant Professor of Medicine, Section of
Comprehensive Medicine
Relapsing polychondritis, once thought to be a
rare disease, is being reported with increasing
frequency. It is a characteristic systemic disease
which involves primarily cartilaginous tissue with
an inflammatory and destructive process. It oc-
curs equally in both sexes with a maximum fre-
quency in the fourth decade. The most common
clinical features are: bilateral auricular chron-
dritis, non-erosive sero-negative inflammatory
polyarthritis, nasal chondritis, ocular inflamma-
tion, respiratory tract chondritis , and audioves-
tibular damage.
The diagnosis is based primarily on the clini-
cal features ivith three or more of the above or
one of the above plus histologic confirmation
considered adequate. Fifty per cent present with
auricular chondritis or the arthropathy . Labora-
tory and radiologic studies are of help mainly to
rule out other possibilities. Corticosteroids are
generally the drug of choice with recent reports
of success with dapsone.
The mortality rate is reported from 22 per
cent to 30 per cent with about half of the deaths
due to respiratory involvement. Although the
etiology is unknown, there is a frequent associa-
tion with other rheumatic diseases. An autoim-
mune cause also is postulated.
Case Presentation
Doctor Cooley:
M.C. is a 64-year-old white male with a six-
month history of weakness, fatigue, anorexia,
a 15-pound weight loss and vague antero-lateral
chest wall pain. He also complained of worsening
dyspnea on exertion, orthopnea and pedal edema.
Over the month prior to admission, he had noted
nightly low-grade fevers not associated with
chills. He was otherwise asymptomatic.
Physical examination on admission showed a
cachectic, chronically-ill-appearing middle-aged
male. Vital signs: BP of 100/60 mm Hg, pulse
of 92. respiration of 30, and temperature of 36.8°
C. The chest examination revealed dullness to
percussion, decreased breath sounds and de-
creased tactile fremitus at both bases, diffusely
scattered rhonchi and point tenderness over the
left ribs. The cardiac examination was normal.
The liver had a span of 14 cm.; the spleen was
not palpable. Rectal examination showed heme
negative stool. The lower extremities had 2 +
edema. Neurological examination was remark-
able only for depression and tearful affect.
Laboratories on admission: WBC was 10,100
with a normal differential; Hb, 9.3 gms; Hct,
28 per cent with normal indices; platelet count.
329,000; ESR. 126/hr: electrolytes, 12/60,
CPK, and LI A were within normal limits except
for an alkaline phosphatase of 265 mu /ml: chest
\-ray showed cardiomegaly, bilateral pleural
effusions, emphysematous lung fields but no
masses or infiltrates; and EKG showed left ven-
tricular hypertrophy and left atrial hypertrophy.
32
The West Virginia Medical Journal
Benign Transudate
Thoracentesis showed the pleural effusion to
be a benign transudate. The patient was begun
on oral digoxin and furosemide with the gradual
resolution of his congestive heart failure. PPD
was negative, with positive control skin tests.
Multiple stools were hemetest negative. Iron
studies were consistent with an anemia of chronic
disease. A bone marrow biopsy was non-diagnos-
tic, but showed no evidence of malignancy.
Liver-spleen and bone scans were normal. Lltra-
sound of the abdomen and pelvis showed a
questionable pelvic mass. CT scans of the chest,
abdomen and pelvis were normal.
During bis hospital course, the patient was
noted to have evening temperature spikes to
38.5°C. A new. coarse systolic ejection murmur
was noted at the lower left sternal border. 2-D
echocardiogram demonstrated aortic regurgita-
tion and a thickened tricuspid valve, with dense
and shaggy echos suggestive of vegetations.
Multiple blood cultures were without growth. The
patient began to complain of polyarthralgias that
had been plaguing him for months. Subsequent-
ly, he developed a migratory polyarthritis involv-
ing the right knee, right shoulder, left elbow and
the left first metacarpophalangeal joint. Lrethral.
rectal and throat cultures were negative for gon-
orrhea. ANA and rheumatoid factor were nega-
tive.
Develops Episcleritis
The patient developed left episcleritis. One
morning, he was found to have erythema,
warmth, tenderness and boggy swelling over the
bridge of his nose: this resolved within 48 hours.
Subsequently, the patient developed erythema,
warmth and swelling over the cartilaginous por-
tion of his left ear: these findings resolved spon-
taneously within 24 hours. Given this constella-
tion of symptoms, a presumptive diagnosis of
relapsing polychondritis was made. He was be-
gun on prednisone 10 mg. orally q.i.d. and dis-
charged from the hospital. He remained asymp-
tomatic hut suffered Cushingoid side effects. The
patient’s prednisone was tapered. Subsequently,
he developed a nasal chondritis and was started
on dapsone. He has remained asymptomatic.
Discussion
Doctor Powers:
Relapsing polychondritis (RPl is a rare dis-
ease of unknown etiology which is being recog-
nized with increasing frequency. Over 200 cases
have been reported in the world literature to
date, compared with 10 cases as of 1960. It is
characterized by episodic, yet generally progres-
sive, inflammation and degeneration of carti-
laginous structures throughout the body, and
recurrent inflammation of special sense organs
including the eye and ear.
This syndrome was first described in 1923
when Jaksch-Wartenhorst 1 reported a 32-year-old
brewery worker in Prague who initially bad joint
swelling and pain associated with fever. Later he
developed in both external ears burning pain and
swelling which, in three months, receded and
shrank, leaving deformed pinnae, complete steno-
sis of both external auditory canals, decreased
hearing, dizziness and tinnitus. He then de-
veloped a painless collapse of the middle segment
of his nose, leaving a saddle deformity. Biopsy
of the nasal septum showed “no cartilaginous
matrix and hyperplastic mucosal membranes.”
During 18 months of followup there was progres-
sion of a peripheral arthritis with a tendency to
deformity. Jaksch-Wartenhorst called this dis-
order polychondropathia.
In 1935. Altherr 2 and Von Meyenberg 3 separ-
ately reported the autopsy of a 14-year-old boy
who had degeneration and destruction of the car-
tilage of his ears, nose, ribs, joints, larynx and
tracheobronchial tree. They named the disorder
chondromalacia. Bean. Drevets and Chapman 4
described one patient and summarized eight pre-
vious cases from the literature in 1958. and
suggested the name of chronic atrophic poly-
chondritis. Finally. Pearson, Kline and New-
comer.’’ in 1960. reviewed 10 previously reported
cases and added four additional ones. They
suggested the name “relapsing polychondritis.”
which is now generally accepted.
RP has been reported in all ages, but seems
to fit a normal distribution with maximal fre-
quency in the fourth decade. The average age
of onset is 44. It is equally divided between the
sexes. The majority of cases reported have been
Caucasian: however, the disease has been seen
in Asians. Hispanics and Blacks. It does not
demonstrate a familial predisposition; however,
there is one report of a pregnant woman with
RP delivering a newborn who was similarly af-
fected at birth. Another pregnant woman with
RP reportedly delivered a normal newborn.
Clinical Presentation
In 1976. McAdam et al. 6 reported the results
of a prospective study of 23 patients, and re-
viewed the world literature to establish the most
common presenting symptoms of RP. These
findings were further supported in a report of
10 cases from the Cleveland Clinic in 1979.'
Chondritis of the auricles and the arthritis of
RP are the most common presenting manifesta-
February. 1983, Vol. 79, No. 2
33
tions, accounting for approximately one half of
cases. The incidence of nasal chondritis, ocular
inflammation and respiratory tract involvement is
divided approximately equally, and accounts for
the majority of remaining presentations. Pa-
tients presenting with audiovestibular symptoms
and other miscellaneous syndromes make up the
remaining small fraction.
Auricular chrondritis is typically bilateral, and
presents as the sudden onset of marked redness,
swelling, warmth and pain, limited to the carti-
laginous portion of the external ears (helix, anti-
helix, tragus, and sometimes the external audi-
tory canal). It is frequently described as having
a violaceous hue. The ear is very tender to
touch; the redness may include surrounding
retroauricular soft tissues and may be accom-
panied by lymphadenopathy. An important point
in the differential diagnosis is that the ear lobe,
lacking cartilage, is always spared.
The inflammation usually subsides within 5-10
days but may last as long as four weeks. After a
single prolonged attack or repeated shorter at-
tacks, loss of cartilage in the ear results in the
pinna becoming flabby and droopy; it may even
flop up and down as the patient walks. These
external ear changes are frequently referred to as
“cauliflower ears.”
Arthritis of RP
The arthritis of RP, the second most common
presenting sign, is an inflammatory, oligo- or
polyarthritis which tends to be asymmetric, and
may involve the large and small joints of the
upper extremity, hips, knees, ankles, occasionally
the spine, and has a predilection for costo-
chondral junctions, sterno-manubrial, or sterno-
clavicular joints. It is sero-negative and usually
non-erosive. At the onset the pattern is often
migratory, frequently associated with effusions,
and can mimic closely rheumatoid arthritis or a
spondylitic variant syndrome.
Occasionally the arthritis is monoarticular,
very acute, and suggestive of infectious or
crystal-induced arthritis. On x-ray there may he
narrowing of the joint spaces or eburnation (de-
generative conversion of bone or cartilage into
a hard ivory-like mass with increased density on
rotentgenograms as a result of inflammation),
but usually no destruction.
RP also can develop in patients with pre-
existing chronic polyarthritis of various types
( Reiter’s syndrome, juvenile chronic polyarthri-
tis, seronegative polyarthritis of the rheumatoid
type) .
The nasal chondritis often is of sudden onset,
with the nose being very painful, red and in-
flamed. It may be associated with a feeling of
tremendous fullness in the bridge of the nose
and surrounding tissues, and occasionally mild
epistaxis. After repeated bouts of inflammation,
the nasal cartilage can collapse, forming the
“saddle nose” deformity, but there have been
reports of deformity without overt inflammation.
In one patient the deformity developed over-
night while asleep.
Ocular inflammation may involve almost every
part of the eye and adnexal structures. The most
common types of eye involvement are conjuncti-
vitis, episcleritis, iritis and keratitis, with addi-
tional reports of cataracts, optic neuritis, extra-
ocular muscle palsy, and exophthalmos. When
ocular inflammation is the only presenting symp-
tom, RP is unlikely and the differential diagnosis
extensive.
Respiratory Tract Involvement
Respiratory tract involvement is a relatively
unusual presenting feature of RP but is note-
worthy because it represents critical and po-
tentially lethal organ system involvement. The
epiglottis, bronchial and thyroid cartilage may
be involved. The patient may complain of ten-
derness over the trachea or larynx. Hoarseness,
at times to the point of aphonia, is a common
complaint. Some present with dyspnea, char-
acterized as asthma-like, often with severe in-
spiratory stridor. Many have an associated
cough, usually non-productive, rarely with minor
hemoptysis.
Eleven of the 14 patients in McAdam’s series
who presented with respiratory complaints re-
quired a tracheostomy, and four eventually died
with respiratory complications. The need for
tracheostomy may be due to collapse of laryngeal
or tracheal cartilage, or due to severe glot-
tic, laryngeal, and subglottic inflammation and
edema, leading to airway obstruction. Respira-
tory tract involvement is the main cause of death
from RP, accounting for almost 50 per cent of
the cases when the cause is known.
Unusual Manifestations
Another less common presenting symptom is
middle or inner ear involvement manifested
by sudden or gradual onset of unilateral or bi-
lateral cochlear and/or vestibular nerve involve-
ment. The symptoms of nausea, vomiting, verti-
go, tinnitus and deafness may he transient or
persistent. Conductive hearing loss due to serous
otitis as a result of swelling of the eustachian tube
cartilage may improve somewhat with resolution
of the swelling and fluid. Sensorineural hearing
impairment and vestibular dysfunction are pre-
34
The West Virginia Medical Journal
sumed to be due to arteritis of the internal audi-
tory artery or its vestibular branch.
Rarely, patients present with diffuse, severe,
systemic symptoms of fever, anorexia, weight
loss, arthralgias and myalgias, and represent
diagnostic dilemmas until other more specific
signs of RP appear.
The incidence of specific organ system in-
volvement in 159 patients also was reported by
McAdam. 6 The approximate order of occurrence
was: ll auricular chondritis, 89 per cent: 2)
polyarthritis or other articular involvement, 81
per cent; 31 nasal chondritis, 72 per cent: 41
ocular inflammation. 65 per cent; 51 respiratory-
tract chondritis, 56 per cent: and 61 audio-vesti-
bular damage, 46 per cent. Less common are
cardiovascular involvement, 24 per cent (val-
vular. nine per centl, and cutaneous lesions, 17
per cent. A frequent associated finding not in-
cluded in McAdam’s series is anemia (found in
10 per cent of Cleveland Clinic series. I 7
The most common cardiac abnormality is
aortic insufficiency. Heart failure, as a result, has
on occasion responded to digoxin and furosamide
but may require valve replacement. Hemody-
namically, the most significant cardiovascular
lesion results from the involvement of the ascend-
ing aorta and secondary dilatation of the aortic
annulus leading to aortic regurgitation. The his-
topathological lesions in the aorta are due to
medial involvement by the inflammatory process
consisting of perivascular infiltration, increased
vascularization and replacement of the elastic
tissue by collagen tissue (similar to cystic medial
necrosis ) .
Aortic Regurgitation
In the past, it was thought that aortic regurgi-
tation in RP was secondary to dilatation of the
aortic ring and not due to valve cusp involve-
ment. Although thickening of the valve cusps
was seen in a few instances, it was thought to be
secondary to mechanical trauma produced by the
regurgitation. However, in a case reported by
Sohi et al. in 1981, 8 aortic cusp involvement by
the inflammatory process, causing hemodynamic
impairment without clinically and grossly ob-
vious involvement of the ascending aorta or the
aortic ring, was the first cardivascular abnor-
mality. Pertinent to their finding is the fact that
abnormalities in the composition (amino acids
and lipids) of the aortic cusps were reported in
1971 by Alexander et al. 9 Other valvular ab-
normalities include a few reports of mitral in-
sufficiency. with one report of a “floppv mitral
valve” presenting simultaneously with RP. 10
Additional cardiovascular abnormalities re-
ported include a 25-per cent incidence of in-
flammatory vascular disease; aneurysm, throm-
bosis or vasculitis has occurred in the descending
or abdominal aorta and in medium-sized arteries,
subclavian, hepatic, superior mesenteric and
peripheral arteries. Pericarditis, cardiac isch-
emia, arrhythmias, etc., have been reported but
have not acquired significance in terms of fre-
quency of occurrence.
Skin lesions also may be a feature of RP, and
are thought possibly to reflect an underlying
systemic vasculitis since the majority reported
are vasculitic in nature. In addition to erythema
nodosum-like lesions, there have been reports of
retardation of nail growth, maculopapular erup-
tions, vesicular lesions and alopecia in one pa-
tient.
Diagnostic Criteria
With the frequencies of organ-system involve-
ment in mind, McAdam empirically arrived at six
proposed diagnostic criteria: 6
1. Recurrent chondritis of both auricles
2. Non-erosive inflammatory arthritis
3. Chondritis of nasal cartilages
4. Inflammation of ocular structures includ-
ing conjunctivitis, keratitis, scleritis/epi-
scleritis and or uveitis
5. Chondritis of the respiratory tract involv-
ing laryngeal and/or tracheal cartilages
6. Cochlear and/or vestibular damage mani-
fest by neurosensory hearing loss, tinnitus,
and/or vertigo.
McAdam felt that the diagnosis is based pri-
marily upon the unique clinical features, and is
quite certain if three or more criteria are present
together with histologic confirmation.
In the 1979 report from the Cleveland Clinic,
Damiani and Levine proposed an expansion of
the criteria for diagnosis of RP. They feel that
a diagnosis of RP can be made when one or more
of McAdam’s signs are present along with posi-
tive histologic confirmation; the diagnosis also
can be made when chondritis is present in two
or more separate anatomic locations and there is
response to steroids and/or dapsone. They based
this proposal on the limited differential diagnosis
of both the syndrome complex of RP and of three
of the first five individual signs, namely auricular
chondritis, nasal chondritis and larvngotracheal-
hronchial chondritis. Diagnosis of RP based on
these expanded criteria may lead to early diagno-
sis and arrest of the disease prior to manifesta-
tions of its other signs. Early diagnosis and
treatment should be strongly encouraged in the
February, 1983, Vol. 79, No. 2
35
face of an illness with respiratory or cardio-
vascular involvement that carries a mortality of
22 per cent.
Pathology
Histologic examination of cartilage from a
clinically involved site will confirm the under-
lying chondritis. The cartilage specimen may
he obtained from the ear, nose or respiratory
tract — keeping in mind that one does not want
to produce any additional cosmetic deformities.
The histologic changes of RP are easily recog-
nized in florid form.
First, in a brief review of normal cartilage, the
two basic components are the cellular (chondro-
cytes) and intercellular matrix (fibrillar elements
and ground substance). The ground substance is
composed of macromolecules called mucopoly-
saccharides and mucoproteins. The cartilage
chondrocytes lie imbedded in the inter-cellular
matrix. The matrix stains basophilic with hema-
toxylin and eosin and metachromatic with certain
other stains.
In relapsing polychondritis, the primary ab-
normality appears to be in the mucopolysac-
charide component of the ground substance, re-
sulting in structural weakness. Light microscopy
shows loss of basophilic staining of cartilage ma-
trix, perichondral inflammation, and cartilage
destruction with replacement by fibrous tissue.
There is lacunar breakdown and infiltration of
neutrophils: as inflammation continues, there is
condensation into irregular whorls of collagen
with plasma cells and lymphocytic infiltration.
Chondrocytes dedifferentiate, forming fibro-
blasts and collagen fibers. Occasionally, small
sites of cartilage regenerate. There is loss of
matrix acid mucopolysaccharides, which results
in the loss of basophilic staining. The primary
change is loss of matrix acid mucopolysac-
charides followed by a secondary perichondral
inflammatory reaction.
The pathogenesis and etiology of RP are not
clearly defined. However, the primary abnormal-
ity appears to lie in the dissolution of the muco-
polysaccharide component of the ground sub-
stance by enzymatic proteolysis.
Experimental Models
Animal models using papain protease injected
intravenously into young rabbits can produce
rapid, diffuse depletion of cartilage matrix and
collapse of the ears. 11 The same effect has been
demonstrated with high doses of vitamin A. sug-
gesting that vitamin A somehow activated pro-
teolytic enzymes with similar properties to
papain protease. 12 Rarranco 11 treated rabbits
with vitamin A and methylprednisolone or with
vitamin A and dapsone and showed no collapse
or dissolution of cartilage. Rabbits treated only
with vitamin A showed collapse of cartilaginous
components.
The cause of the proposed activation of pro-
teolvtic enzymes is not known. A hypersensitivity
reaction has been suggested by Glynn and Hol-
borrow, 14 who postulated that a bacteria or virus
combined with chondroitin sulfate and protein
in cartilage to form an antigenic substance. This
would result in auto-antibody formation with
antigen-antibody complexes activating comple-
ment. resulting in destruction of cartilage.
Immunological Abnormalities
Circulating anticartilage antibodies bave been
demonstrated by several investigators. An anti-
cartilage antibody has been shown by direct im-
munofluorescence in a patient with RP. 1 ’ In a
1981 report by Ebringer et al. 16 cartilage anti-
bodies were demonstrated by indirect immuno-
fluorescence on human fetal cartilage in six of
nine patients with RP. The highest titers were
present during the early acute phase of the dis-
ease.
Another 1981 report 1 ' demonstrated anti-
bodies against rat costal cartilage in an RP
patient’s serum. Fiodart 18 demonstrated circulat-
ing antibodies to type II collagen during the
acute phase of RP by indirect immunofluores-
cence after removal of proteoglycan.
The significance of these findings remains ob-
scure as such antibody may be an accompani-
ment of cartilage destruction and not its cause.
There also have been reports of cell-mediated im-
munity to cartilage. 19,20
Co-existing Diseases
The co-existence of various rheumatic or
“auto-immune" diseases noted in RP patients
suggests a possible immunological mechanism
underlying RP. The associated disease usually
precedes the development of RP. McAdam di-
vided the patients in his series into those with
“pure” RP (about 75 per cent) and those with
a co-existing rheumatic or autoimmune disease
I about 25 per cent ). Rheumatic diseases include
rheumatoid and juvenile rheumatoid arthritis.
Sjogren’s syndrome. SLE. systemic sclerosis,
Reiter’s svndrome or psoriatic arthritis: the auto-
immune diseases include thvroid disease (goiter.
Hashimoto’s thyroiditis or hyprothvroidism ) ,
ulcerative colitis, glomerulonephritis, dvsgamma-
globulinemias and non-caseating granulomas.
More recent reports include Wegener’s granu-
lomatosis. periarteritis nodosa, diabetes mellitus
36
The West Virginia Medical Journal
with insulin resistance, vitiligo and antibodies to
human intrinsic factor and gastric parietal cells.
There has been a report of RP associated with
carcinoma of the pancreas, and one report of RP
preceding Hodgkin s disease by six months.
Differential Diagnosis
The differential diagnosis of RP may be ex-
tensive. If the auricular chondritis is bilateral,
resolves spontaneously, and is recurrent, the
differential diagnosis is almost exclusively
limited to RP. Trauma or infection are other
possibilities. However, infectious perichondritis
is usually associated with fever, leukocytosis,
regional adenopathy, clears with antibiotics, and
initially may have been associated with trauma,
mastoid surgery or chronic external otitis. The
most frequent etiologic agent causing infectious
perichondritis is Pseudomonas aeruginosa.
Calcification of cartilaginous structures of the
ear as found in 40 per cent of patients with RP
also has been reported in Addison's disease,
ochronosis, acromegaly, essential hypertension,
diabetes mellitus, hyperthyroidism and familial
cold hypersensitivity.
Nasal chondritis also must be differentiated
from infectious nasal perichondritis, which usual-
ly has positive cultures and responds to anti-
biotics. Nasal collapse resulting in saddle nose
deformity also may be seen in congenital syphilis
or Wegener’s granulomatosis. A negative RPR
and FTA-ABS, and lack of renal involvement,
pulmonary parenchymal involvement or central
or peripheral nerve involvement would help to
rule out these respective diseases.
Other Similar Diseases
The articular manfestations of RP may be
similar to rheumatoid arthritis, but RP-associated
arthritis usually is not destructive and not asso-
ciated with rheumatoid nodules or positive rheu-
matoid factor.
Reiter’s syndrome resembles polychondritis
because of the arthritis and eye lesions, but
differs in that the urethral, dermal, and mucosal
lesions commonly seen in Reiter’s are not seen
in RP.
Several entities have similar ocular inflamma-
tion, including Reiter’s syndrome, rheumatoid
arthritis, Still’s disease. Behcet’s disease, entero-
pathic arthritis. Wegener’s granulomatosis, poly-
arteritis nodosa. Sjogren s svndrome (kerato-
conjunctivitis sicca and xerostomia!. Cogan’s
syndrome I interstitial keratitis and vestibular
auditory problems such as severe vertigo, tin-
nitus. ataxia and bilateral sensory neural deaf-
ness), syphilis, herpes zoster and entities with
arteriosclerosis.
The differential diagnosis of laryngeal trach-
eal bronchial chondritis seen in RP is limited
to infectious perichondritis, of which there
could he many causes.
Laboratory Findings
The laboratory is only helpful in the diagnosis
of RP when it serves to exclude other conditions.
The only consistent findings are an elevated
erythrocyte sedimentation rate during active dis-
ease. often with a moderate leukocytosis and
mild-to-moderate anemia. The anemia is usually
normochromic and normocytic with low serum
iron and iron binding capacity ( i.e.. anemia of
chronic disease I .
Other laboratory findings tend to be non-
specific indicators of inflammatory disease. There
have been a few cases of renal disease (specifical-
ly glomerulonephritis) associated with RP. but
there was thought to be another active disease
process to account for it. There have been re-
ports of elevated liver function tests, but these
are usually attributed to passive congestion due
to heart failure.
Radiographic, findings includ calcification of
the ears, nose and trachea: cardiovascular in-
volvement with cardiomegaly or pulmonary con-
gestion: or narrowing of joint spaces with ebur-
nation. But most important is the use of ra-
diology in evaluating the respiratory system. In
addition to PA and lateral views of the chest, a
PA and lateral soft-tissue view of the neck should
be done to search for narrowing of the cervical
trachea. Further delineation may be obtained by
tracheal tomograms with or without radio con-
trast dye.
Therapy
Medical treatment of RP consists primarily of
corticosteroids, immunosuppressive drugs and
dapsone ( diaminodiphenylsulfone I . Salicylates,
phenylbutazone, naprosyn and indomethacin
have been tried and have been reported to
he effective in some cases, but are not the
drugs of choice. A number of cases responding
to dapsone have been reported in the past six
years. 1 3,21,22 It is theorized that dapsone func-
tions in RP by inhibition of lysosomal enzyme
release and thereby prevents chondrocyte dam-
age. The range of dosage was 25 mg. to 200 mg.
per day for one week to two years. The average
dose was 75 mg. per day for four months. Side
effects include lethargy, nausea, and hemolvtic
anemia (especially in G6PD deficiency). Serious
rashes, agranulocytosis and aplastic anemia have
been reported.
February. 1983. Vol. 79. No. 2
37
Steroids Drug of Choice
Steroids are probably still the drug of choice
in treating RP — especially in the face of a life-
threatening illness. Corticosteroids have been
reported to be almost uniformly reliable in abat-
ing acute periods of activity, and in decreasing
the frequency and severity of recurrences. They
frequently are effective in laryngotracheal and
external ear manifestations and in decreasing the
sedimentation rate, but not always as helpful in
the eye manifestations or in treating the sen-
sorineural hearing loss.
The starting range is usually 30-60 mg. of
prednisone per day with larger doses during
periods of intense disease activity. The average
daily maintenance dose is 20 mg. per day for
a period of four months. Alternate-day therapy
generally has been ineffective. When resolution
of RP was seen, steroids were tapered, hut there
have been a number of cases that were never able
to withdraw completely without an exacerbation.
In general, it is thought that the response to
therapy is related to the aggressiveness of the
disease. A number of patients that have not re-
sponded to steroids alone have been tried on
immunosuppressive drugs (azothiaprine, cyclo-
phosphamide, alkeran, methotrexate, plaquinil,
nitrogen mustard and 6-mercaptopurine) with
some success.
Surgical Treatment Limited
Surgical treatment of RP is limited. Tra-
cheostomy may be necessary for respiratory dis-
tress secondary to tracheal/laryngeal /bronchial
chondritis. Whether or not to treat the nasal
collapse cosmetically is debated in the literature,
with some reports of further deformity resulting.
One point agreed upon is that no surgery should
be attempted while the disease is in an active
phase. Cardiovascular involvement may necessi-
tate replacement of affected valves, or resection
of aneurysms.
Prognosis
Mortality rates for RP are usually reported to
be 22 per cent to 30 per cent after four to five
years of disease. Almost half the deaths are due
to respiratory involvement, mainly airway col-
lapse. Other causes of death reported are pneu-
monia, ruptured aneurysm, vasculitis, cardio-
vascular (a few post-operative valve replace-
ment), congestive heart failure, and malignancy.
A more common prognosis for RP is a low-grade
and smoldering course over many years with
good control of symptoms with the use of cortico-
steroids.
References
1. Jaksch-Wortenhorst R: Polvchondropathia. "Wien
Arch Intern Med 1923; 6:93-100.
2. Alther RF: Uber einen Fall von systematisierter
Chondromalacie. Virchows Arch F Pathol Anat 1936;
297:445-479.
3. Von Meyerburg R: Ueber chondromalacie. Schweiz
Med Wochenschr 1936; 17:1239.
4. Bean WB, Drevets CC, Chapman JS: Chronic
atrophic polychondritis. Medicine 1958; 37:353.
5. Pearson CM, Kline HM, Newcomer VD: Relapsing
polychondritis. N Engl J Med 1960; 263:51.
6. McAdam LP et al.: Relapsing polychondritis:
Prospective study of 23 patients and a review of the
literature. Medicine (Baltimore) 1976; 55(3): 193-215.
7. Damiani JM, Levine HL: Relapsing polychondritis
—Report of ten cases. Lanjngoscope 1979; 89:929.
8. Sohi GS et al.: Aortic cusp involvement causing
severe aortic regurgitation in a case of relapsing poly-
chondritis. Cathet Cardiovasc Diagn 1981; 7:79-86.
9. Alexander CS et al.: Abnormal amino acid and
lipid composition of aortic valve in relapsing polvchon-
dritis. Am J Cardiol 1971; 28:337.
10. Hemry DA et al.: Relapsing polychondritis, a
“floppv” mitral valve, and migratorv polvtendonitis.
Ann Intern Med 1972; 77:576-580.
11. McCluskey RT, Thomas L: The removal of
cartilage matrix in vivo, by papain. J Exp Med 1958;
108:371.
12. Thomas L et al.: Comparison of the effects of
papain and vitamin A on cartilage. ] Exp Med 1980; 3:
705.
13. Barranco V, Mino D, Salamon H: Treatment of
relapsing polychondritis with dapsone. Arch Dermatol
1976; 112:1286-1288.
14. Glynn LE, Holborrow EJ: Conversion of tissue
polysaccharides to autoantigens by Group-A Beta-Hemo-
lytic streptococci. Lancet 1952; 2:449-451.
15. Rodgers JH, Boden G, Jourtellatte CD: Relapsing
polvchondritis with insulin resistance and antibodies to
cartilage. Am J Med 1973; 55:243-248.
16. Ebringer G et al. : Autoantibodies to cartilage and
type II collagen in relapsing polychondritis and other
rheumatic diseases. Ann Rheum Dis 1981; 40-473-479.
17. Meyer O et al.: Relapsing polychondritis— Patho-
genic role of anti-native collagen type II antibodies.
I Rheumatol 1981; 8:820-824.
18. Fiodart JM et al. : Antibodies to type II collagen
in relapsing polvchondritis. N Engl J Med 1978; 299:
1203.
19. Herman JH, Dennis MV: Immunopathologic
studies in relapsing polvchondritis. J Clin Invest 1973;
52:549-558.
20. Rajapakse DA, By waters EG: Cell-mediated im-
munity to cartilage proteoglycan in relapsing polychron-
dritis. Clin Exp Immunol 1974; 16(3): 497-502.
21. Martin J et al.: Relapsing polychondritis treated
with dapsone. Arch Dermatol 1976; 112:1272.
22. Ridgway HB et al.: Relapsing polychondritis:
Unusual neurological findings and therapeutic efficacy of
dapsone. Arch Dermatol 1979; 115:43.
38
The West Virginia Medical Journal
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OUR LEGISLATIVE PROGRAM
T)y the time you read this the Legislature will
he in session. Measures recommended by the
Steering Committee of the Association's Com-
mittee on Legislation and approved for sponsor-
ship by the Council are intended to provide a
more rational and reasonable system for the trial
or settlement of medical malpractice actions.
When enacted, this system should help reduce
the cost of liability insurance and thereby de-
crease the cost of medical care for all.
A brief summary of measures our Association
has introduced include those to: (1) limit the
statute of limitations to a more reasonable time
frame: (2) introduce collateral sources of pay-
ments for damages: (3) determine reasonable
and equitable contingency fees for attorneys: (4)
eliminate demands for outlandish sums of money
in claims: (5) establish reasonable limits to
awards for non-economic loss; (6) establish de-
grees of liability proportionate to the degree of
responsibility if more than one party is involved:
(7 ) provide for periodic payment of damages so
the award goes to the injured party: and ( 8) pro-
vide appropriate copies of records to be available
to patients.
This legislation will not be a shield to protect
MDs or to prohibit lawsuits for negligence. Any-
one who has an injury from negligence is entitled
to just, reasonable, and equitable compensation
for it. The key words, though, are “just, reason-
able. and equitable." A medical misadventure is
not a reason to reap windfall profits for the pa-
tient or the attorney, any more than having an
operation should he a reason for the patient to
submit bills to three different insurance com-
panies to profit from the illness.
The intent of our legislative program is to put
a damper on unreasonable and exhorbitant
awards, disproportionate to the injuries sus-
tained. to plaintiffs and attorneys alike, not to
deny reasonable, just and equitable compensa-
tion to those who have truly suffered injury. We
must pass this measure on to our legislators, our
patients and the public. If we do not, in the end
all of us will pay the inflated cost.
In discussing these and other issues with sev-
eral members of the Legislature, I have found
them receptive and willing to listen. They ap-
preciate knowing the facts, for these issues are
clouded by emotion, and emotional issues are
hard to deal with rationally and logically. The
ball is in our court now. If you. the Membership,
are not interested enough to initiate a discussion,
make a phone call, or write a letter, we cannot
expect the members of the Legislature to be
interested enough to make the hard choices re-
quired of these emotion-laden issues. They want
and need the information we can provide in
order to make some hard decisions. It is the duty
and responsibility of each one of us to do all
be or she can to provide this information. We
must not abdicate this responsibility.
Harry Shannon. M. D.. President
West Virginia State Medical Association
40
Thf, West Virginia Medical Journal
The Vest Virginia riedical Journal
Editorials
The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or
in communications submitted to this Journal for publication. The author shall be held entirely responsible.
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State
Medical Association.
Among 50 recommendations given the Gover-
nor and the Legislature by the state's Health
Cost Containment Task Force was one calling
for creation of another such study group in the
general area of malpractice insurance.
In summary, the recommendation called for
a task force, with members knowledgeable about
insurance, law and medicine.
PRIORITY GOOF "to specifically consider in-
surance and tort law reforms
for the resolution of complaints of medical and
hospital malpractice."’
But when the cost containment task force was
putting its final report together, and ranking in
order of priority various recommendations under
the so-called "hospital medical" group, it placed
the malpractice problem issue 11th on a list
of 12.
State Attorney General Chauncey Browning,
who chaired the health care cost study unit
created by Governor Rockefeller on September
28, 1981, explained that the task force — which
held 13 monthly meetings over a period of more
than a year — simply did not have time to study
this particular issue.
To some, that wasn't a very adequate answer.
Browning himself earlier had commented that
there was no group in West Virginia “that knows
more about the health care cost situation than
this Task Force. That being the case, how did
the growing professional liability problem fall
down the crack? The force’s final report indi-
cated that it didn t — at least, not entirely.
“It was brought to the attention of the Task
Force that malpractice insurance for hospitals
and physicians is an expenditure that increases
the costs of health care." the report noted. “Due
to their specialty, some physicians pay more
than $20,000 per year for malpractice insurance."
The report continued:
“In addition, it is said that many laboratory
tests and x-rays are routinely ordered merely for
malpractice prevention rather than because there
is any reasonable need for the services."
Then came the observation that “this Task
Force has considered many areas, and has not
had the time to concentrate upon the malpractice
area to the extent necessary to develop a recom-
mendation that would propose a solution to the
problem.”
Accordingly, “This Task Force recommends
the appointment of another group to specifically
consider the malpractice problem."
A lack of time by the health care cost study
group to consider this particular issue now is the
proverbial water over the dam. But how a Task
Force that considered itself as most knowledge-
able about health care costs could rank the pro-
fessional liability problem No. 11 on a list of 12
items must remain somewhat of a mystery.
Maybe, in all of its work, the group didn t
have time to read a newspaper every now and
then. That’s really all that would have been
necessary to get some inkling of the scope of the
difficulty.
We will be a long time getting over missing
Clark Sleeth. Much will be said and written
about our gentle contemporary. Especially will
those who matured under his wise direction in
the School of Medicine try to express his worth
to them, and he unable to
CLARK KENDALL put their thoughts into
SLEETH, 1913-1982 words that mean what they
feel about Clark. Even
more so do we, his equals in time, find it hard
to say what our hearts are shouting inside as we
keep missing him. There is a great urge to pay
him tribute by way of the written word. And so
we surrender to it. knowing full well the effort
will not say it adequately.
When we first knew him as assistant in Doctor
Van Liere's physiology department in the old
medical school — we of the last great class of
84 souls to be admitted to the old school —
his always friendly mien and his concern were
like soothing unguent to our eroding egos as we
struggled to stay afloat in the first year’s un-
February, 1983, Vol. 79, No. 2
41
certain seas. And it’s hard to separate that Clark
from the one we have known in recent years, for
he has never changed from the always dignified
but cheerful and witty, friendly and encouraging
helper of all who came to him for support. And
he has shared those benefits with countless
patients as he has practiced the art of healing
with the same intensity which was part of his
every endeavor.
We will leave to others the telling of his
scientific, scholastic and administrative talents
which so notably served the need of our Uni-
versity Medical Center. For example, the De-
partment of Family Practice will pay him tribute
for its existence, and for being perhaps the most
effective among the host of determined and hard-
working family doctors who for years had been
pushing for its founding. But those are not the
things we miss about Clark, for the torch of these
responsibilities passed smoothly from his weary-
ing hands to other capable ones.
So it’s pretty hard to pinpoint the why about
our missing Clark. We have wonderful Nellie
to call on and talk to, and everything she is has
a lot to do with our missing him. It’s just hard
to say. But we will take a long time to get over
missing Clark Sleeth. And maybe we never will.
— JNJ
As indicated in The Journal's January issue,
several so-called tort reform bills are a part of
the State Medical Association’s 1983 legislative
program. In that light, the fol-
GOLD RUSH lowing comments by Charles D.
Hollis, Jr., M. D., President of the
Medical Association of Georgia, not only are
interesting, but call new attention to some key
components of the liability insurance dilemma.
Here’s Doctor Hollis:
“The alarming escalation of frequency and
severity of malpractice claims is not just a
problem facing hospitals and physicians. The
staggering sums of money awarded must ulti-
mately come from patients, thus becoming a
significant factor in the increase in all medical
costs. But the awarded monies are only the tip
of the iceberg. Otherwise unnecessary tests,
x-rays, and hospitalizations ordered as a pro-
tection against medical malpractice claims in-
crease utilization and constitute as much as an
estimated 30 per cent of the total health care
expenditures. This is 30 per cent of the $300
billion spent on health care services annually
in this country. From a personal perspective,
I believe that these estimates are realistic.
“Thus, in the professional liability fiasco, we
are dealing with a social problem, not just with
a medical economics problem. It is of such
magnitude that we are compelled to take legis-
lative action to offer relief to the public. We
must look to our friends in the Legislature to
find meaningful and constitutionally sound tort
reform laws.
“It won’t be easy. The plaintiff bar has to
consider the hundreds of millions of dollars in
contingency fees and will thus oppose any effort
to improve the professional liability insurance
climate. But, I believe it is possible — if we
teach the business community and our patients
what is involved. A well planned and coordi-
nated effort will be necessary. Indiana has
implemented model tort reform legislation which
has withstood challenges in the courts. As a
consequence, Indiana physicians and patients
have been spared the apprehension, frustration,
and expenses faced by physicians, hospitals, and
their patients in most states.
“The public welfare is involved. As concerned
physicians, we cannot afford to allow the gold
rush by the plaintiff bar to block efforts now
to effectuate meaningful tort reform.”
Violation of Ethics
On April 15, 1982, in Indianapolis, Indiana, an in-
nocent, defenseless newborn human being was killed
(murdered) by starvation and dehydration with the
sanction of the courts. Infant Doe was not only refused
surgical care to correct an esophageal-tracheal fistula,
but had fluids and food withheld until the baby died six
days later. Why was this allowed to happen? Because
he was something less than “normal.” He had Down’s
Syndrome.
Where is the blame to be put for such a blatant act?
Surely the parents must be blamed for being unwilling to
accept their responsibility. Certainly the courts must ac-
cept blame. To me, however, the most blame must lie
with the doctor who, by doing what he did, no matter
at whose insistence, violated every principle of medical
ethics. A doctor’s responsibility is always to attempt to
cure, not to kill. What a precedent this could set-
accepting killing as an acceptable mode of treatment.
I have seen this case reported in medical literature but
I have not seen it condemned in medical literature. Has
the abortion (killing) ethic so inured us that such actions
are now acceptable? Even if the courts declare such
conduct to be legal, should the medical profession blindly
follow? I hope and pray not!
Clarence H. Boso, M. D.
Huntington, WV
42
The West Virginia Medical Journal
GENERAL NEWS
Program For Annual Meeting
Begins To Take Shape
Two general scientific programs featuring
symposia on sexually transmitted and cardiovas-
cular diseases will feature the West Virginia
State Medical Association’s 116th Annual Meet-
ing August 25-27.
The convention at the Greenbrier in White
Sulphur Springs will
get under way with
the usual Council
meeting on Thursday
morning, August 25,
and the first House of
Delegates session that
afternoon.
Frank J. Jirka, Jr.,
M. D., Chicago area
urologist who will take
office in June as the
American Medical As-
David z. Morgan, m. d. sociation President,
has been invited to
address the first House meeting.
The initial general scientific session at 9:45
A.M. on Friday, August 26, will be preceded
by the traditional opening exercises. A keynote
speaker for that program will be announced
later.
David Z. Morgan, M. D., of Morgantown, the
Annual Meeting Program Committee Chairman,
said the symposium on sexually transmitted
diseases Friday morning will include papers on
these individual topics:
Syphilis and gonococcal infections: non-luetic,
non-gonococcal venereal diseases; transmissible
diseases of the gay patient, and sexual mores
in the 1980s.
The Program Committee will announce later
speakers for this symposium, as well as for the
cardiovascular disease program on Saturday
morning, August 27, and upcoming issues of
The Journal will provide such details.
Saturday morning topics will include new
developments in the management of cardiac
arrythmias; an update relative to cardiovascular
surgery, and the management of congestive heart
failure.
Specialty Meetings Planned
In addition to the general sessions, the Annual
Meeting agenda will include breakfast, luncheon
and other programs arranged by specialty
societies and sections, many of which also will
provide scientific discussions.
The specialty group meetings will be held in
large measure on Friday, with a few to be set
for Saturday morning, preceding the second
general session, and at noon.
The House of Delegates will hold its second
and final session on Saturday afternoon, at which
time Carl R. Adkins, M. D., of Oak Hill will be
installed as the Association’s 1983-84 President
to succeed Harry Shannon, M. D., of Parkers-
burg.
Continuing a practice of many years, the
Auxiliary to the State Medical Association, with
Mrs. Richard S. Kerr of Morgantown the cur-
rent President, will hold its meeting in con-
junction with that of the Association.
Others serving with Doctor Morgan on the
1983 Program Committee are Doctor Adkins;
Jean P. Cavender, M. D., Charleston; Michael
J. Lewis, M. D., St. Marys; Kenneth Scher,
M. D., Huntington, and Roland J. Weisser, Jr.,
M. D., Morgantown.
Reservation forms provided by the Greenbrier
were mailed to Association members with Execu-
tive Secretary Charles R. Lewis , annual bulletin
early in January.
The membership is urged to give the matter
of reservations its earliest possible attention. If
forms for some reason did not reach physicians,
others may be obtained from the Association’s
headquarters office, P. 0. Box 1031, Charleston
25324.
Congress’ Lame Duck Session
Leaves AMA-FTC Deadlock
The American Medical Association and
Federal Trade Commission fought to a standstill
in the lame duck session of Congress, with the
final version of the continuing resolution funding
various agencies of government until early this
February, 1983, Vol. 79, No. 2
43
year omitting any mention of the FTC’s having,
or not having, jurisdiction over the professions.
That leaves the situation where it was two
years ago, hut AMA lobbyists did succeed in
removing the language of the Rudman Amend-
ment. which was adopted by a vote of 15-14 by
the Senate Appropriations Committee.
The Rudman Amendment prevailed when the
Chairman, Senator Mark Hatfield, Oregon Re-
publican, was called upon to break a 14-14 tie.
The Senate tabled, or killed, by a 59-37 vote,
the proposal that would have prevented the FTC
from investigating or taking action against
medicine or other state-regulated professions.
At 6 A. M. the morning of December 16, the
House adopted the language of the Rudman
Amendment ( similar to the Broyhill Amend-
ment ) giving FTC jurisdiction over the pro-
fessions.
AMA lobbyists went to work to prevent the
adoption of this language, which would have
established FTC’s jurisdiction. The result of that
effort was the expunging of the Rudman langu-
age from the continuing resolution, leaving the
long controversy right where it was.
The AMA bill, to remove any doubt of FTC
jurisdiction over the state-regulated professions.
Review A Book
The following books have been received by the
Headquarters Office of the State Medical Associa-
tion. Medical readers interested in reviewing any
of these volumes should address their requests to
Editor, The West Virginia Medical Journal. Post
Office Box 1031, Charleston 25324. We shall be
Tiappy to send the books to you, and you may
keep them for your personal libraries after sub-
mitting to The Journal a review for publication.
Current Obstetric and Gynecologic Diagnosis
and Treatment , 4th Edition, edited by Ralph
C. Benson. M. D. 1.038 pages. Price $25.
Lange Medical Publications, Los Altos, Cali-
fornia 94022. 1982.
Basic and Clinical Pharmacology, by Bertram
G. Katzung. M. D.. Ph.D. 815 pages. Price
$23.50. Lange Medical Publications, Los Altos.
California 94022. 1982.
Nine Months’ Reading: A Medical Guide for
Pregnant IV omen , 3rd Edition, by Robert E.
Hall. M. D. 178 pages. Price $13.95. Double-
day & Company, Inc.. 245 Park Avenue, New
York. New 5 ork 10167. 1983.
will have to be introduced in the new Congress,
which convened in January.
In the meantime, the regulatory agency’s
authority over medicine is now the law of only
the Second Circuit, not the law of the land.
The 4-4 U. S. Supreme Court decision, which
gave no opinion and thus set no precedent,
merely let stand the decision in that circuit.
Family Physicians’ Meeting
Scheduled In April
“Physician, Heal Thyself" will be the theme
for the opening session of the 31st annual
scientific assembly of the West \ irginia Chapter.
American Academy of Family Physicians, to be
held April 15-17.
Gordon H. Deckert, M. D. Donald L. Cooper, M. D.
The meeting site will be the Lakeview Inn
and Country Club in Morgantown, with the first
session to begin Friday morning, April 15.
Some 15 physicians and others will make up
the faculty for the scientific sessions which, in
addition to the Friday morning session, will be
held Friday afternoon. Saturday morning and
afternoon, and Sunday morning.
The opening session will be presented in two
parts, “Physician. Know Thyself" and “Physi-
cian, Linderstand Thyself." by Gordon H.
Deckert. M. D., and Jane Chew Deckert. B. D.,
M. S. Doctor Deckert is Professor and Head.
Department of Psychiatry and Behavioral
Sciences, F niversity of Oklahoma College of
Medicine, Oklahoma City. Presentation tech-
niques will include dramatization and structured
group exercises.
The Assembly program is acceptable for 18
and one-half Prescribed hours by the AAFP,
and is approved for the same number of hours
44
Thf. West Virginia Medical Journal
/ii
Donald S. Robinson, M. D
in Category 1 of the Physician’s Recognition
Award of the American Medical Association.
Family physicians will be welcomed to the
scientific assembly by Dr. Robert D. Hess of
Clarksburg, President. Opening remarks will be
made by Drs. Arlo P. Brooks, Jr., of Parkers-
burg, President Elect and Program Chairman,
and Harry Shannon, also of Parkersburg. Presi-
dent of the State Medical Association.
Other Speakers
Other speakers and their topics will be:
Friday Afternoon: “What Is Your Fitness?’ -
— Donald L. Cooper, M. D., Director. Student
Health Center. Oklahoma State University;
"Dealing with the Impaired Physician " — Perry
R. Ayers, M. D., Clinical Professor, Department
of Preventative Medicine, Harding Hospital.
V orthington. Ohio: and “Office Management
of Family Physicians' Practices” — David C.
Scroggins, M.B.A., C.P.B.C., Clayton L. Scrog-
gins Associates, Inc., Cincinnati.
Saturday Morning: “Diagnosis and Treat-
ment of Sleep Disorders : “Respiratory Im-
pairment in Sleep — Clinical Manifestations,
Diagnosis and Current Treatment Approaches”
Helmut S. Schmidt, M. D., Director, Sleep
Disorders Evaluation Center. Ohio State Uni-
versity, Department of Psychiatry, Columbus;
"Now I Lay Me Down to Sleep . . . Insomnia”
Thomas Roth. Ph.D., Director, Sleep Dis-
orders and Research Center, Henry Ford Hos-
pital, Detroit; and “Pharmacology and Ther-
apeutics of Hypnotic Drugs” — Donald S.
Robinson. M. D.. Chairman and Professor. De-
partment of Pharmacology, and Professor of
Medicine, Marshall University.
Saturday Afternoon: “Peptic Ulcer Disease”
— George J. Brodmerkel, Jr., M. D., Head.
Division of Gastroenterology, Department of
Medicine, Allegheny General Hospital, Pitts-
burgh; “Treatment of Low Back Pain" —
Gerald R. Gehringer. M. D., Professor and Head,
Department of Family Medicine, Louisiana
State L niversity, New Orleans; and national
President. AAFP; “Hypertension Treatment for
Family Physicians” — Joseph M. Pitone, D.O.,
Assistant Professor of Medicine, Department of
Nephrology and Hypertension. University of
Medicine and Dentistry of New Jersey, New
Jersey School of Osteopathic Medicine; and
Head. Subsection. Department of Nephrology
and Hypertension. John F. Kennedy Memorial
Hospital, Stratford (New Jersey) Division: and
“A Recent Update on Beta Blockers” — Wayne
A. Border. M. D., Chief of Nephrology, Uni-
versity of Utah, Salt Lake City.
Headaches in Children
Sunday Morning: “Recent Advances in Treat-
ment of Headaches in Children" — Arnold D.
Rothner. M. D.. Chief, Section of Child
Neurology, The Cleveland Clinic Foundation;
“The Use of Thrombolytic Therapy in Venous
Thromboembolic Disease" — Ronald N. Rubin.
M. D., Director, Oncology L T nit, and Assistant
Professor of Medicine, Temple University Hos-
pital: “New Concepts in Rheumatology" —
Steven Abramson, M. D., Assistant Professor of
.Medicine. New V ork University Medical Center.
New V ork City: and “Senile Dementia” — James
T. Hartford, M. D., Associate Professor and
Chief. Geriatric Psychiatry, University of
Cincinnati.
Additional meeting details are scheduled to
appear in the March issue of The Journal. Mean-
while. registration and other information may
be obtained by calling I 304 ) 776-1178.
David J. Fine Named To Fill
WVU Hospital Post
David J. Line, Senior Associate Director of
the University of Nebraska Hospital and Clinic
at Omaha, has been appointed Administrator of
West Virginia University Hospital.
John L. Jones, M. D., WVU Vice-President
for Health Sciences, said Fine assumed his new
duties in January on a part-time basis and would
be full-time within three months.
He succeeds Eugene L. Staples who resigned
to become director of the University of Kansas
Medical Center hospital last June. Associate
Administrator Bernard G. Westfall has been serv-
ing in the interim.
Fine. 32. was born in Flushing, New York, and
is a graduate of Tufts University and the Uni-
versity of Minnesota.
February, 1983, Vol. 79, No. 2
45
Continuing Education
Activities
Here are the continuing medical education
activities listed primarily by the West Virginia
University School of Medicine for part of
1983, as compiled by Dr. Robert L. Smith,
Assistant Dean for Continuing Education, and
J. Zeb Wright, Ph. D., Coordinator, Con-
tinuing Education, Department of Community
Medicine, Charleston Division. The schedule is
presented as a convenience for physicians in plan-
ning their continuing education program. (Other
national, state and district medical meetings are
listed in the Medical Meetings Department of
The Journal. )
The program is tentative and subject to
change. It should be noted that weekly confer-
ences also are held on the Morgantown, Charles-
ton and Wheeling campuses. Further information
about these may be obtained from: Division of
Continuing Education. WVU Medical Center,
3110 MacCorkle Avenue, S. E., Charleston
25304; Office of Continuing Medical Education.
WVU Medical Center, Morgantown 26506: or
Office of Continuing Medical Education, Wheel-
ing Division, WVU School of Medicine, Ohio
Valley Medical Center. 2000 Eoff Street. Wheel-
ing 26003.
Eeb. 6-9, Snowshoe, Surgical Conference
March 18, Charleston, 10th Annual Newborn
Day
March 25-26, Morgantown, Infection Control
Workshop
March 28-29, White Sulphur Springs, Sym-
posium on Tumors for the Orthopedic
Surgeon
April 28, Wheeling, Balance Disorders
April 29, Charleston, Research Day
April 29-30, Morgantown, Orthopedic Reunion
Days
May 7, Charleston, Outpatient Infectious
Diseases
May 12-13, Morgantown, Health Officers Con-
ference
Regularly Scheduled Continuing
Education Outreach Programs from
WVU Medical Center/
Charleston Division
Buckhannon , St. Josephs Hospital, first-floor
cafeteria, 3rd Thursday, 7-9 P. M. — Feb.
( winter break )
March 17, “Thyroid Dysfunction: Diagnosis
and Management,” Richard Kleinmann, M. D.
April 21, “Prenatal Disorders and Congenital
Anomalies,” R. Stephen S. Amato, M. D.
Cabin Creek, Cabin Creek Medical Center,
Dawes, 2nd Wednesday, 8-10 A. M. — Feb.
9, “Evaluation and Treatment of Burns,”
Augusto Portillo, M. D.
March 9, “Overall Outpatient Management of
Renal Dysfunctions,” Mary Lou Lewis, M. D.
Gassaway, Braxton Co. Memorial Hospital, 1st
Wednesday, 7-9 P. M. — Feb. 2, “Yes, Vir-
ginia, There Are Venereal Diseases in Rural
Practices,” Patrick Robinson, M. D.
March 2. “Enteral Alimentation." Brittain
McJ unkin, M. D.
April 6, “Clinical Intervention in Drug &
Alcohol Abuse,” Thomas Haymond, M. D.
Madison, 2nd floor. Lick Creek Social Services
Bldg., 2nd Tuesday, 7-9 P. M. — Feb. (winter
break ) .
March 8, “Drug & Alcohol Abuse: Interven-
tion Strategies,” Thomas Haymond, M. D.
Oak Hill, Oak Hill High School ( Oyler Exit, N
19) 4th Tuesday, 7-9 P. M. — Feb. (winter
break ) .
March 22, “End-Stage Renal Disease,'" Mary
Lou Lewis, M. D.
April 26. “Adolescent Sexuality: Recognizing
& Treating Pathological Behavior," T. 0.
Dickey, M. D.
IVelch, Stevens Clinic Hospital. 3rd Wednesday,
12 Noon-2 P. M. — Feb. (winter break).
March 16, “Protocols for Treating Poisonous
Snake Bites,” David 0. Wright, M. D.
W hitesville, Raleigh-Boone Medical Center, 4th
Wednesday, 11 A. M.-l P. M. — Feb. (winter
break ) .
March 23, “Hypertension Update: Diagnosis
& Management,” Stephen Grubb. M. D.
April 27, “Obesity: Emotional Factors in
Compliance,” John Linton, Ph.D.
46
The West Virginia Medical Journal
Williamson, Appalachian Power Auditorium. 1st
Thursday, 6:30-8:30 P. M. — Feb. (winter
break ) .
March 3, “Suicide Intervention,” Martin
Kommor. M. D.
New Dean Said ‘Outstanding’
For Era Of Change
A West Virginia University search committee
considered nearly 70 persons before recommend-
ing Dr. Richard A. DeVaul of Texas for the post
of Dean of the WVU School of Medicine.
This was noted by Dr. John E. Jones, WVU
Vice-President for Health Sciences, who called
Doctor DeVaul “a man
of outstanding cre-
dentials and accom-
plishment, and note-
worthy scholarship.”
Doctor Jones also com-
mented, “We believe
he will provide the
kind of leadership
needed in the era of
substantial change
which the WVU School
of Medicine is enter-
mg.
Doctor DeVaul,
whose appointment was announced in December,
will take over the WVU post this spring. He
currently is Associate Dean for Student and
Curriculum Affairs at the University of Texas
Medical School at Houston.
Specializing in psychiatry. Doctor DeVaul, 42,
received his medical degree from the University
of Rochester, and did his psychiatric residency
at Johns Hopkins University.
A native of Ames, Iowa, Doctor DeVaul re-
ceived his bachelor of science degree from Iowa
State University, graduating with the highest
scholastic honors. During his medical education
at Rochester, he was awarded a summer fellow-
ship in cardiology at Stanford University.
Navy Flight Surgeon
After a year of internal medicine residency at
University Hospitals in Iowa City, he was a
Navy flight surgeon for three years with the
Presidential helicopter squadron at Quantico,
Virginia, before entering psychiatry residency.
Doctor DeVaul joined the psychiatry faculty
at the University of Texas Medical School in
Houston in 1974, also serving as Director of
Liaison Psychiatry. He also has appointments in
the Departments of Medicine and Family Prac-
tice, continuing that work after becoming As-
sociate Dean in 1979.
Since 1975 he has been coordinator for the
Health Science Center’s Pain Clinic, and last
year served as Chairman of the Center’s Educa-
tion Task Force.
Doctor DeVaul was Steering Committee Chair-
man for the University of Texas System Health
Professional Schools in 1977-78. He has been
an examiner for the American Board of
Psychiatry and Neurology, and consultant to a
review group of the National Institute of Mental
Health.
Research, Clinical Interests
Since 1975 he has authored or co-authored 61
publications, abstracts or other presentations.
His research and clinical interests cover a wide
range, from chronic pain syndrome and the
grieving process to emotional factors in illness
and drug dependency.
He is co-author of “Psychiatry’s Role in
Medical Education," a chapter in the new book.
Psychiatry in Crisis.
Doctor Jones was Dean of the Medical School
from 1974 until his appointment last April as
Vice-President. Dr. Robert H. Waldman, Chair-
man of the Department of Medicine, has been
serving as Interim Dean.
The search committee for the new Dean was
headed by Dr. Alvin L. Watne at WVU.
AM A Panel To Evaluate
New Procedures
The American Medical Association’s role in
technology assessment has expanded with the ap-
pointment of 500 physicians to serve on the new
Diagnostic and Therapeutic Technology Assess-
ment I DATTA ) project. Selected panelists will
answer queries from business, industry, govern-
ment agencies, and the medical profession on the
benefits, risks, and cost-effectiveness of new pro-
cedures. With the guidance of the Council on
Scientific Affairs, the DATTA panelists will
examine medical technologies that are passing
from experimental or investigational use to ac-
cepted forms of treatment. DATTA will define,
where possible, indications for their use.
No fewer than 20 participating physicians will
be asked to contribute their expertise in develop-
ing responses to each outside inquiry. The
panelists' opinions will be tabulated, and a con-
sensus will be issued as to whether a procedure
Richard A. DeVaul, M. D.
February, 1983, Vol. 79, No. 2
47
should be considered as established, investiga-
tional. unacceptable, or indeterminate. When a
consensus cannot be reached, the council may
call for a special study, conference, or report.
In the future, DATTA panelists will be
selected by the council from nominations
solicited from all segments of the AMA.
HHS Starts Fraud Hot Line
For Its Programs
A nationwide toll-free hot line has been
established by the U. S. Department of Health
and Human Services to receive information
about fraud, waste, and abuse in any of the De-
partment's 350 programs, including Medicare
and Medicaid. The number is (800) 368-5779.
Operators in the Inspector General's office will
answer.
As a pilot for the national hot line, HHS set
up a local Washington number two years ago.
More than 5,900 federal workers and taxpayers
have used the local number to report fraud and
abuse. About 10 per cent of the complaints
resulted in remedial action. In one case, the
administrator of a federal program and two con-
tractors went to jail for overcharging Medicare
by $567,000.
Physicians’ Image Both
Positive, Negative
Physicians' public image remains excellent in
some areas, according to a public opinion survey
conducted by an independent research firm for
the American Medical Association. In 1.504
telephone interviews with randomly-selected
respondents, the majority said that physicians
are accessible in an emergency (81 per cent),
explain things well to their patients (55 per
cent), take a genuine interest in their patients
(68 per cent), are up-to-date on the latest ad-
vances in medicine (71 per cent), and genu-
inely are dedicated to helping people (80 per
cent ). Some 65 per cent disagreed with a state-
ment that physicians act as if they are better
than other people.
I lie image was tarnished, however, in other
areas. People are beginning to lose faith in
physicians, said 62 per cent of the respondents.
They agreed with statements that physicians are
too interested in making money I 60 per cent),
and disagreed with statements that physicians’
fees usually are reasonable (57 per cent dis-
agreed), and that physicians spend enough time
with their patients (52 per cent disagreed).
Medical Meetings
Feb. 8-12 — Am. College of Emergency Physicians,
Surgery/Trauma, Detroit.
Feb. 11-13 — Biomedical Topics in Psychiatry (Medi-
cal College of VA), Hot Springs, VA.
Feb. 18-20 — Regional CME Meeting, Am. College of
Physicians, Alexandria, VA.
March 4-6 — Am. Medical Student Assoc., Cleevland.
March 5-12, Canadian Am. Medical Dental Assoc.,
Vail, CO.
March 10-15 — Am. Academy of Orthopedic Sur-
geons, Anaheim, CA.
March 20-24 — Am. College of Cardiology, New Or-
leans.
April 7-8 — WV Chapter, Am. Academy of Pediatrics,
Beckley.
April 15-17 — WV Chapter, AAFP, Morgantown.
April 16-21 — Am. Academy of Pediatrics, Phila-
delphia.
April 17-21 — Am. Urological Assoc., Las Vegas.
April 17-22 — Operative Treatment of Fractures &
Nonunions (Johns Hopkins University), Hot
Springs, VA.
April 18-22 — Am. Roentgen Ray Society. Atlanta.
April 22-24 — Medical Staff Leadership Seminar
(Southern Medical Assoc.), Hilton Head, SC.
April 24-28 — Am. Assoc, of Neurological Surgeons,
Washington. D. C.
May 4-7 — WV Chapter, Am. College of Surgeons,
White Sulphur Springs.
May 6-8 — Southern Medical Assoc. Regional Post-
graduate Conference, Lexington. KY.
May 8-12 — Am. College of Obstetricians & Gyne-
cologists, Atlanta.
May 13-14 — Topics in Cardiovascular Diseases (Am.
Heart Assoc.), Baltimore.
June 19-23 — Annual Meeting of AMA House, Chi-
cago.
Aug. 25-27 — 116th Annual Meeting, W. Va. State
Medical Assn.. White Sulphur Springs.
Sept. 29-Oct. 2 — Am. Society of Internal Medicine,
San Francisco.
Oct. 16-21 — Am. College of Surgeons, Atlanta.
Nov. 6-9 — Scientific Assembly, Southern Medical
Assoc.. Baltimore.
48
Thf. West Virginia Medical Journal
SAAB HAS
MORE CARGO SPACE
THAN BMW,
AUDI, AND VOLVO.
COMBINED.
Flip down the back seat of a Saab and you get
56.5 cubic feet of cargo space (53 in a 4-door
model).
Now compare that to the 16 cubic feet you
get in an Audi 5000. The 13. 9 you get in a Volvo
GLT Turbo. Even the posh 22.5 you get in a
BMW 733i (and see how much good posh does
you when you’re packing up the summer house).
Of course, you can’t flip down the back seat of
any of these cars. So they might say Saab has an
unfair advantage.
We couldn’t agree more.
The most intelligent car ever built.
WVU Medical Center
—News—
Compiled from material furnished by the Medical Center
News Service, Morgantown, W. Va.
Nephrology Chief Receives
National Kidney Award
Frederick C. Whittier, Jr., M. D., Professor
of Medicine and Chief, Nephrology Section, has
been named a recipient of a Distinguished Service
Award by the National Kidney Foundation. He
received the award for his concern and dedica-
tion on behalf of the Foundation and its pro-
grams.
A member of the Foundation for 11 years,
Doctor Whittier has been active on both the
Affiliate and National levels. On the Affiliate
level, he served as President of the National
Kidney Foundation of Kansas and Western
Missouri and as Chairman of its Medical Ad-
visory Board. Nationally, he has served as
Chairman of the National Medical Advisory
Board, the Sub-committee on Organ Donation
and as a member of tbe Foundation’s Executive
Committee.
Doctor Whittier also served as Program Chair-
man of the Foundation’s Clinical Dialysis and
Transplant Forum for two years beginning in
1978.
A member of the Editorial Board of tbe
Foundation’s official journal, tbe American
Journal of Kidney Diseases, Doctor Whittier also
is a member of numerous other organizations
including the American Society of Nephrology,
the American Society of Artificial Organs, the
American Association of Tissue Banks, the
Transplantation Society and the American
Society of Transplant Physicians.
Emergency Helipad At WVU
Hospital Donated
WVU Hospital will soon have its first paved,
lighted and close-in landing pad for helicopters,
a gift of James A. LeRosa, Jr., Clarksburg coal
operator and businessman.
The landing site, used in bringing critically ill
or injured patients to tbe Medical Center, will be
located about 30 yards from the emergency de-
partment entrance. A grassy site about 150
yards from the emergency entrance was used
previously.
“In the past we had to use an ambulance to
transport patients from the landing site to the
hospital.” said John S. Veach, M. D., Assistant
Professor of Surgery and Medical Director of the
Emergency Department. “Now we’ll have a
direct paved walkway, and can bring patients
in on wheeled stretchers.”
Coordinator for the gift was Alvin L. Watne,
M. D., Chairman of Surgery. He said the gift
was made in kind, with construction materials
and work crews and equipment being provided
by LaRosa’s firm. Lights donated by Sharpe
Electric Co. of Weston will be installed later.
The project involves major earth moving and
transporting some 3,000 cubic yards, or 130
truckloads, of fill, paving a 40-foot diameter
landing pad with six inches of concrete over six
inches of crushed rock, and a 10-foot walkway
30 feet long to the Emergency Department drive.
The fill is about eight feet deep at the outer edge,
sloping to nearly ground level adjacent to the
driveway.
“This will mean a marked improvement in
our ability to work with critically ill patients
being transported by helicopter,” said Dr. Walter
H. Moran, Chief of Emergency Services. “The
pad will be lighted in accord with FAA regula-
tions, and is in an area cleared of obstructions.”
Doctor Wible Heads State
Pediatrics Chapter
Kenneth L. Wible, M. I)., of the pediatrics
faculty is the new Chairman of the West Virginia
Chapter of the American Academy of Pediatrics.
Doctor Wible, Associate Professor, took office
for a tbree-year term at the Academy’s recent
national convention in New York City.
A graduate of Juniata College and the Medi-
cal School of Thomas Jefferson University in
Philadelphia. Doctor Wible joined tbe WVU
faculty in 1969. He is Director of the Medical
Center’s pediatric group practice.
x
The West Virginia Medical Journal
“The rehabilitation of head-injured patients
is an intensive, sophisticated procedure”
says Jose Amayo, M.D., Hamiarville Rehabilitation Center
“From morning ’til night, head-injured
patients are involved in rehabilita-
tion,” says Dr. Amayo, director of
Harmarville’s head injury program.
“Our program has four primary
elements: cognitive retraining to
improve memory, attention span and
communication skills; physical restor-
ation services to help patients relearn
walking and caring for themselves;
a vocational program to prepare
patients for employment, further
training or education; and programs
to help patients deal with routine
social and recreational activities.
“We also use a computer and
new diagnostic tools, like die evoked
potential system. This sophisticated
equipment permits us to measure
hearing, vision and sensation.”
Other special
Harmamille programs:
• Pain program to help patients
control and live with pain,
particularly neck- and back-
injured persons.
• Neuro-spinal program for the
rehabilitation of quadriplegics
and paraplegics.
• Claims Assessment for Rehabil-
itation Evaluation and Services
(CARES) for returning injured
workers to maximum level of
function and employment.
For more information on Harmar-
ville, its head injury program and
admission procedures, call Dr.
Amayo, 781-5700.
Harmarville Rehabilitation Center, P.O. Box 11460, Guys Run Road, Pittsburgh, PA 15238
Third-Party News, Views
and Program Concerns
Caution In Prospective Payment
System Advised By AMA
The American Medical Association has cau-
tioned the Congress to proceed slowly in imple-
menting a system for prospective payment for
hospital services.
Joseph F. Boyle, M. D., Chairman of the AMA
Board of Trustees, recently told a congressional
committee that the AMA supported developing
and exploring payment systems for institutions
based on “predetermined rates or other payment
systems that create incentive for facilities to be
more cost-conscious.”
He warned, however, that “it would be in-
appropriate to institute a radical change in the
Medicare and Medicaid hospital reimbursement
system without assurances that quality care will
be maintained.”
Doctor Boyle also cautioned against imple-
menting any full-scale prospective payment
system “without experimentation and until on-
going projects have been analyzed to determine
their effects on costs and quality.”
Effects in Human Terms
Testifying before the Health Subcommittee
of the House Commerce Committee, the AMA
official urged Congress to “consider not only
how much these programs are designed to save
in terms of dollars but also what effects they
will have in human terms and upon the quality
of care that will be available to the American
people.”
In his testimony, Doctor Boyle emphasized
that “decisions made in the near future con-
cerning how hospitals and other providers are
reimbursed will have long-range implications on
access to and the quality of care for years to
come.”
Hospitals, through their boards, admini-
strators, and medical staffs, are likely to respond
to changes in the reimbursement system to try
to maintain access and quality care, he said. If
hospitals find they are being under-reimbursed.
xii
he continued, likely actions will be shifting costs
to other payers, deferring such spending as
maintenance ( often leading to higher long-term
costs), and postponing or eliminating necessary
modernization and technological improvements,
depriving patients of the highest quality of care.
“In extreme cases, hospitals providing es-
sential care could be forced to close.” he warned.
Further Demonstrations Urged
Current data are not adequate to confirm
that prospective payment is an appropriate
nationwide reimbursement system. Doctor Boyle
continued. “We strongly urge that further
demonstrations go forward before any attempt
is made to radically alter the manner in which
payment is made for hospital care.”
Lacking, he said, is detailed information about
what long-term changes would occur in hospitals
under a prospective payment system. “What
do we do if the ‘incentives’ change behavior in
a way that cuts costs but also forces elimination
of needed services and activities?,” he asked.
“Considerations such as these are best answered
through demonstration projects prior to the
nationwide implementation of a new Medicare
reimbursement system."
“It is important to determine not only
whether there are short-term savings that may
be generated by a prospective payment system,
but also whether the hospitals will continue to
be able to provide quality care.”
Access Could Be Hindered
The physician pointed out that while prospec-
tive payment systems could be tailored to achieve
cost savings, “the question of side effects . . .
must be considered.” He quoted a General Ac-
counting Office report earlier this year warning
that “there is a point when a reduction in
reimbursement could adversely affect access to
and or quality of care for beneficiaries. Also,
if the prospective reimbursement does not apply
to all payers, a facility can have an incentive
to shift costs to non-covered payers."
The West Virginia Medical Journal
PHYSKIANS
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Obituaries
KENNETH E. BLUNDON, M. D.
Dr. Kenneth E. Blundon of Eugene, Oregon,
formerly of Charleston, died on November 17,
1982, at his home. He was 64.
Doctor Blundon retired as a urologist in 1978,
having been Chief of Urology at Sacred Heart
General Hospital in Eugene from 1968 to 1972.
A native of Washington, D. C.; he practiced
in Charleston from 1953 until moving to Eugene
in 1962.
He was a former member of the Kanawha
Medical Society and the West Virginia State
Medical Association.
Survivors include the widow; two sons,
Kenneth J. Blundon of Springfield, Oregon;
Parke E. Blundon of Seattle; a daughter, Elaine
Price of Grants Pass, Oregon, and a sister, Mrs.
Martha Halluin of Gambrills, Maryland.
* # #
A. C. WOOFTER, M. I).
Dr. A. C. Woofter, Parkersburg internist from
1934 until 1980, died on December 16, 1982,
in a Parkersburg hospital. He was 75.
Doctor Woofter was a Past President and
honorary member of the Camden-Clark Memorial
Hospital staff, and was the first Chairman of the
hospital's Department of Internal Medicine. He
also was a member of the staff at St. Joseph’s
Hospital.
A native of Weston, Doctor Woofter was
graduated from West Virginia Wesleyan College,
and received his M. D. degree in 1933 from
the University of Michigan.
He interned at Mercy Hospital in Toledo,
Ohio.
He was a Diplomate of the American Board
of Internal Medicine, and a Fellow of the Ameri-
can College of Physicians and the American
College of Cardiology.
Doctor Woofter was an honorary member and
Past President of the Parkersburg Academy of
Medicine, and an honorary member of tbe West
Virginia State Medical Association and American
Medical Association.
He also was an honorary member and Past
President of the West Virginia Heart Associa-
tion and the Wood County Heart Association,
and was a member of the International Society
of Internal Medicine.
Doctor Woofter served as a major in the U. S.
Public Health Service from 1942 to 1946.
Surviving are two sons. Andrew C. Woofter.
Jr., and Joseph C. Woofter, M. D., both of
Parkersburg.
* * *
SIEGFRIED WERTHAMMER. M. D.
Dr. Siegfried Werthammer, former Chairman
of the Marshall Llniversity School of Medicine
Pathology Department, died on January 2 in
Sarasota, Florida. He was 71.
A native of Vienna, Austria, Doctor Wert-
hammer received his M. D. degree in 1935 from
the University of Vienna.
He came to Huntington in 1939 as Director
of Pathology at the former Huntington Memorial
Hospital.
Doctor Werthammer was Chief Pathologist
and Director of Laboratories at St. Mary’s Hos-
pital in Huntington from 1942 to 1961, and was
Chief of Pathology at Cabell-Huntington Hos-
pital from 1955 to 1979.
He developed the pathology residency training
program at Cabell-Huntington for the MU
School of Medicine.
Doctor Werthammer was a former member of
the Cabell County Medical Society and the West
Virginia State Medical Association.
Surviving are the widow; a daughter, Ann
Roth of Huntington, and a son. Dr. Joseph
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xiv
The West Virginia Medical Journal
Your profession
can help protect you...
with group insurance
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Sponsored by the West Virginia State Medical Association:
■ Long Term Disability Income Protection
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Mail to Administrator: McDonough Caperton Shepherd Association Group
P.O. Box 3186, Charleston, WV 25332
Telephone: 1-304-347-0708
County Societies
MONONGALIA
The Monongalia County Medical Society met
on December 7. The principal speaker was
Edward Pastilong, Assistant Athletic Director at
West Virginia University. His guests were
Darryl Talley, Mark Raugh and Todd Campbell,
all WVU varsity football players.
Dr. Richard A. DeVaul, newly appointed
Dean of the WVU School of Medicine, was
introduced to the Society.
The Society approved a donation of $5,000
to the Morgantown Hospice, Inc. This sum will
be matched by the Hazel Ruby Foundation.
A moment of silence was observed in the
memory of the late Drs. Clark K. Sleeth and
Bernard Zimmermann. — Robert L. Murphy,
Executive Secretary.
# * *
TYGART’S VALLEY
The Tvgart’s Valley Medical Society met on
November 18 at the Elkins Motor Lodge in
Elkins.
Dr. Harry Shannon of Parkersburg, President
of the State Medical Association, addressed the
Society on a variety of subjects concerning the
Association and the medical profession.
Dr. Carl H. Cather, Jr., of Morgantown was
the scientific speaker. His topic was “Ear, Nose
and Throat Allergy.’' — Michael M. Stump,
M. D., Secretary.
EQUIPMENT WANTED
WANTED TO BUY— Second hand office
and exam room equipment. Also, instru-
ments appropriate for Family Practice.
Send responses to P. 0. Box 1645, Beckley,
WV 25801.
Over 40 Practice Opportunities
In rural West Virginia
CONTACT
Health Professions Recruitment Project
West Virginia Department of Health
1800 Washington Street, East
Charleston, West Virginia 25305
Phone: 348-0575
OFFICERS OF COMPONENT SOCIETIES
Society
President
Secretary
Meetings
Boone
Sriramloo Kesari
Madison
Manuel T. Uy
Madison
2nd Tues.
Brooke
Rogelio L. Velarde
Follansbee
W. T. Booher, Jr.
Wellsburg
Cabell
Charles E Turner
Huntington
S. Kenneth Wolfe
Huntington
2nd Thurs.
Central West Virginia
Joseph B. Reed
Buckhannon
Greenbrier Almond
Buckhannon
As Sched.
Eastern Panhandle
John S. Palkot
Martinsburg
Francisco D. Sabado, Jr.
Martinsburg
2nd Wed.
Fayette
Amor H. Ramirez
Montgomery
Serafino S. Maducdoc, Jr.
Montgomery
1st Wed.
Greenbrier Valley
Stephen L. Sebert
Lewisburg
Charles E. Weinstein
Ronceverte
2nd Wed.
Hancock
Reynaldo B Vista
Weirton
Timothy A Brown
Weirton
3rd Tues.
Harrison
Gaspar Z. Barcinas
Bridgeport
James E. Bland
Clarksburg
1st Thurs.
Jefferson
Jules F. Langlet
Charles Town
William S Miller
Ranson
1st Wed.
Kanawha
Donald E. Farmer
Charleston
Robert B Point
Charleston
2nd Tues.
Logan
Herbert D. Stern
Logan
Tivitmahaisoon Chanchai
Logan
2nd Wed.
Marion
P. Kent Thrush
Fairmont
Mack 1. McClain
Fairmont
Last Tues.
Marshall
Carlos C. Jimenez
Glen Dale
Jose J. Ventosa
Glen Dale
1st Tues.
Mason
Mel P Simon
Point Pleasant
Richard L. Slack
Point Pleasant
4th Tues.
McDowell
Haresh Khatri
Welch
John S. Cook
Welch
2nd Wed.
Mercer
Mario Cardenas
Princeton
David F Bell, Jr
Bluefield
3rd Mon.
Mingo
Edward B. Headley
Delbarton
Nikhanth Purohit
Williamson
2nd Wed.
Monongalia
N. LeRoy Lapp
Morgantown
Robert Bettinger
Morgantown
1st Tues.
Ohio
Thomas L. Thomas
Wheeling
James C. Durig
Wheeling
4th Tues.
Parkersburg Academy
Billie M. Atkinson
Parkersburg
John E. Beane North Parkersburg
1st Thurs.
Potomac Valley
Suratkal V. Shenoy
Keyser
Larry C Rogers
Keyser
2nd Wed.
Preston
Gary W. Lawrence
Kingwood
C. Y. Moser
Kingwood
4th Thurs.
Raleigh
Jose L. Oyco
Beckley
William C. Covey, Sr.
Beckley
3rd Thurs.
Summers
Jack D. Woodrum
Hinton
Chandra P Sharma
Hinton
3rd Mon.
Tygart's Valley
Karl Myers, Jr.
Philippi
Halberto G. Cruz
Philippi
3rd Thurs.
Western
Herminio L. Gamponia
Spencer
AM H. Morad
Ripley
Bi-Monthly
Wetzel
Donald A. Blum
New Martinsville
K. M. Chengappa New Martinsville
Monthly
Wyoming
Frank J. Zsoldos
Mullens
George F. Fordham
Mullens.
Quarterly
xviii The West Virginia Medical Journal
The West Virginia Hectical Journal
Vol. 79, No. 3 March, 1983
Acquired Factor VIII Inhibitor*
(A Case Report)
SUSAN IRBY, M. D.
Pittsburgh , Pennsylvania
JOHN S. ROGERS II, M. D.
Associate Professor of Medicine, Section of Hema-
tology/Oncology, Department of Medicine, West Vir-
ginia University Medical Center, Morgantown
DOUGLAS C. WOLF, M. D.
Cleveland, Ohio
An elderly woman presenting with gross
hematuria and later gastrointestinal bleeding was
found to have an acquired inhibitor to clotting
Factor VIII. Transfusions with large amounts
of Factor VIII concentrate transiently corrected
the prolonged partial thromboplastin time
( PTT) and the depressed Factor VIII clotting
level.
Additional laboratory abnormalities included
mild prolongations of both prothrombin time
I PT ) and thrombin time ( TT ) which were not
corrected in vitro by the addition of equal
volumes of normal plasma or in vivo by Factor
VIII infusion.
A diagnostic approach to a patient with a
suspected clotting inhibitor is discussed. The
present case is compared to previous reported
cases of acquired Factor VIII clotting inhibitors.
A cquired Factor VIII inhibitors most com-
monly occur in hemophilia patients receiv-
ing Factor VIII infusions but have been de-
scribed in non-hemophiliacs. 1,2,3 ' 4 We report a
patient with an acquired Factor VIII clotting
“This paper was written while Doctors Irby and Wolf
were residents in medicine at West Virginia University
Medical Center, Morgantown.
inhibitor. The present case is compared to
previous reported cases. The need for appropri-
ate diagnosis and treatment is discussed.
Case Presentation
A 72-year-old black female was admitted for
evaluation of gross hematuria of three weeks’
duration. The patient denied previous episodes
of hemorrhage, and had undergone both an
appendectomy and full-mouth dental extraction
in the past without significant bleeding. She
had been taking aspirin for two years for
degenerative arthritic pain, and more recently
eimetidine I Tagamet I for epigastric discomfort.
Her medical history further revealed a poorly
substantiated diagnosis of multiple myeloma
made one year previously. She had been
treated with lumbar radiation and daily oral
dexamethasone (Decadron).
During her recent hospital course, cystoscopv
and retrograde pyelography revealed bleeding
from both ureteral openings, and hydrone-
phrosis of the right kidney. Table 1 shows the
initial coagulation studies. The partial throm-
boplastin time ( PTT I was markedly elevated,
and the prothrombin time (PT) and thrombin
time (TT) were mildly prolonged. The platelet
count and Ivy bleeding time were normal. The
plasma fibrinogen and fibrin split products
I FSP ) were both increased.
Further laboratory evaluation revealed the
presence of a Factor \ III clotting inhibitor of
moderate titer. The PTT was repeated on serial
dilutions of the patient’s plasma with normal
plasma. One would expect a clotting factor de-
March, 1983, Vol. 79, No. 3
49
ficiency to be corrected by an equal volume of
normal plasma, that is, a 1:1 dilution. In our
case, complete correction of the prolonged PTT
did not occur until the 1:8 dilution. Incubation
of the mixture at 37 C for one hour enhanced
the inhibition, i.e., the PTT of the mixture pro-
longed further with time. The patient’s clotting
Factor VIII level (F VIII-C) was decreased to
0.14 units /ml (normal range 0.56-1.55 units/
ml ). Levels of Factors II, V, IX and X were all
normal. Quantitation of the Factor VIII inhibitor
activity by the method described by Kasper 5
revealed a moderate titer of 18 Bethesda units.
Reason Not Clear
While the prolonged PTT is explained by the
Factor VIII inhibitor, the reason for the ab-
normalities in the PT and TT is not clear. The
mixing of equal volumes of patient and control
plasma (1:1 dilution ) produced incomplete cor-
rection of the PT and TT. Transfusions of large
amounts of Factor VIII concentrates corrected
the prolonged PTT and the depressed Factor
VIII level. Table 2 shows normalization of the
Factor VIII level with marked shortening of the
PTT one hour post-infusion. The mild ab-
normalities of the PT and TT were not affected.
The evaluation of our patient for underlying
disease was inconclusive. An abnormal pap
smear was suggestive of malignancy. Following
infusion of a large dose of Factor VIII concen-
trate, cervical biopsy plus dilatation and curet-
tage were performed without significant bleeding.
TABLE 1
Initial Lab Studies
Patient
Normal
PTT
72.0 sec.
31.4 sec.
PT
13.5 sec.
10.6 sec.
TT
43.4 sec.
23.7 sec.
Platelets
375,000/cu mm
140-440, 000/cu
mm
Fibrinogen
530 mg/dl
200-400 mg/dl
FSP
>40 ug/ml
<10 ug/ml
Ivy BT
4 min.
1-6 min.
TABLE 2
Effects of Infusion of 10,000 Units of
Factor VIII Concentrate
Normal
Pre Post
F VIII
1.00 ± .21 u/ml
0.14 u/ml 1.09
u/ml
PTT
33.4 sec.
62.8 sec. 41.4
sec.
PT
11.1 sec.
13.8 sec. 13.2
sec.
TT
23.4 sec.
34.4 sec. 41.2
sec.
The cervical biopsy showed epithelial dysplasia.
The endocervical and endometrial scrapings re-
vealed atypical cells suggestive of malignancy.
The presence of multiple myeloma was not con-
firmed by bone marrow biopsy or by serum and
urinary electrophoresis.
While hospitalized, the patient developed an
upper gastrointestinal bleed. Endoscopy exami-
nation revealed duodenitis. The patient was
continued on the Factor VIII concentrate in-
fusions on a daily basis with control of major
bleeding symptoms. Two weeks prior to dis-
charge she was begun on Prednisone 20 mg.
every six hours. The requirement for Factor
XIII infusions gradually decreased, and she was
discharged on prednisone.
The patient was seen two weeks later as an
out-patient. Both the hematuria and gastroin-
testinal bleeding had resolved. At that time, the
inhibitor titer had decreased to five Bethesda
units. The PTT had decreased to 38.8 sec., and
the Factor VIII level was 0.46 u ml. One month
later, the patient was admitted to another hos-
pital where she died secondary to gastrointestinal
bleeding. An autopsy was denied.
Discussion
The in vitro and in vivo studies in our patient
are consistent with an acquired F VIII inhibitor
of moderate titer. The reason for the mild pro-
longation of the PT and TT in our patient is
uncertain. The incomplete correction of the
TT in vitro by equal volumes of control plasma
and in vivo by Factor VIII concentrate infusion
suggests a second site of inhibition, perhaps due
to the increased fibrin split products. Fibrin
split products are known to have an anti-
thrombin effect. The presence of elevated FSPs
with a normal platelet count and increased
plasma fibrinogen raises the possibility of
compensated disseminated intravascular coagu-
lation ( DIC I or primary fibrinolysis.
Acquired Factor VIII inhibitors occur most
commonly in hemophiliacs, but have been as-
sociated with a variety of disease states. In a
1975 review article, Shapiro 4 cited patients with
long-standing asthma, pemphigus, psoriasis, and
non-specific dermatitis who developed inhibitors
to Factor VIII. Patients with connective tissue
disease such as systemic lupus erathematosis,
rheumatoid arthritis and temporal arteritis
occasionally have inhibitors to Factor VIII.
Anticoagulants also have been found in patients
in the postpartum period. 2 in patients with
dysproteinemias, 6 and have been associated with
50
The West Virginia Medical Journal
reactions to penicillin, nitrofurazone. phenyl-
butazone and sulfa. 3
Non-hemophiliac children have been reported
to develop Factor VIII inhibitors after viral in-
fections. 1 Others have noted a connection be-
tween inhibitors and occult malignancy, and in
elderly patients who are otherwise healthy. 2,3
Factor VIII inhibitors have been described in
patients with cancer, including Hodgkin’s
disease, prostate cancer, myelofibrosis and can-
cer of the cervix.
The Factor VIII inhibitor has been character-
ized as an auto-antibody mainly of the IgG
class. 2 Subtyping reveals the majority to be of
the IgG4 subclass. The light chain is frequently
restricted, with Kappa chains occurring most
commonly in hemophiliacs with inhibitors. The
reaction with Factor VIII follows first order
kinetics and is progressive. The reaction re-
quires several hours and can be dissociated. The
progressive nature of the reaction was apparent
in the correction studies in our patient. The
inhibitor may disappear after several weeks or
may persist for years.
Why the Anticoagulant?
The cause of the circulating Factor VIII anti-
coagulant in our patient is unclear. The diagnosis
of multiple myeloma was not confirmed. In
regard to medication, the patient had been
taking dexamethasone and eimetidine prior to
the onset of hematuria. Neither drug is known
to be associated with Factor VIII inhibitor for-
mation. The possibility exists that the patient
had endometrial or cervical carcinoma.
While the incidence of acquired Factor VIII
inhibitor is low, it may be the cause of significant
morbidity and mortality. Suggested treatment
includes infusion of large doses of Factor
concentrate. If the inhibitor is of low titer, as
in the present case, such an approach may con-
trol bleeding. Plasma exchange transfusions
may be employed in an attempt to decrease the
amount of circulating inhibitor; however, the
effects are transient, as the majority of the IgG
antibody is extravascular. 8
Immunosuppression with cyclophosphamide
or prednisone requires several weeks to months
to affect the inhibitor level, and is frequently
ineffective. Prothrombin complex concentrates
contain Factors II. VII. IX and X. Factors IX
and X may appear in the activated form. Clini-
cal studies involving hemophilia patients with
Factor VIII inhibitors suggest that prothrombin
complex concentrates may partially bypass the
need for Factor VIII in thrombin formation and
improve hemostasis. 8 Newer preparations spe-
cifically designed to contain activated vitamin
K-dependent clotting factors are now com-
mercially available. 9
Acquired clotting Factor VIII inhibitors can
be life-threatening, but with proper diagnosis
and hematological support, bleeding can often
be stabilized. Control of an associated under-
lying disease may lead to the disappearance of
the inhibitor. On occasion, spontaneous remis-
sions or responses to immunosuppression occurs.
Therefore, it is important to be able to recognize
the nature of the bleeding disorder and. if an
inhibitor is found, to search for its cause, while
appropriate hematological support is given.
Acknowledgements
The authors wish to thank Frances S. Jencks
for technical assistance and Annorah L. Cale for
secretarial assistance.
References
1. Brodeur GM, ONeil PJ, Williams JA: Acquired
inhibitors of coagulation in non-hemophiliac children.
1 Pediatr 1981; 96:439-441.
2. Poon M, Wince AC, Ratnoff OD, Bernier GM:
Heterogeneity of human circulating anticoagulants
against antihemophiliac factor (Factor VIII). Blood 1975;
46:409-416.
3. Shapiro S, Hultin M: Acquired inhibitors to the
blood coagulation factors. Semin Thromb Hemostas
1974; 1(4): 336-385.
4. Shapiro S: Characterization of Factor VIII anti-
bodies. Ann \Y Acad Sci 1975; 240:350-361.
5. Kasper CA: More uniform measurement of Factor
VIII inhibitors. Thromb Diathos Haemorrh (Stuttg) 1975;
34:869-872.
6. Lackner H: Hemostatic abnormalities with dyspro-
teinemias. Semin Hematol 1973; 10:125-133.
7. Schleider MA, Nachman RL, Jaffe EA, Coleman
M : A clinical studv of the lupus anticoagulant. Blood
1976; 48:499-509.
8. Penner JA: Efficacy of activated prothrombin com-
plexes. Scand ] Haematol [Suppl] 1980; 24:146-151.
9. Abildgard CF, Penner JA, Watson-William EJ :
Anti-inhibitor coagulant complex (Autoplex) for treatment
of Factor VIII inhibitor in hemophilia. Blood 1980;
56:978-984.
March, 1983, Vol. 79, No. 3
51
Early Attenuation Of Toxic Shock Syndrome
With Intravenous Nafcillin Sodium
THOMAS T. SMIRNIOTOPOULOS, M. D.
Department of Emergency Medicine,
Jefferson Memorial Hospital, Ranson, West Virginia
VETTIVELU MAHESWARAN, M. D.
Department of Obstetrics and Gynecology,
Jefferson Memorial Hospital
A 22-year-old woman presented with an acute
febrile illness suggestive of Toxic Shock syn-
drome. Early treatment with intravenous nafcil-
lin sodium and aggressive fluid replacement
attenuated the majority of signs and symptoms.
Subsequent recovery of coagulase-positive
staphylococcus aureus from vaginal cultures con-
firmed the diagnosis. It is suggested that more
liberal criteria be used to define Toxic Shock
syndrome to allow earlier recognition and treat-
ment and thus prevent morbidity.
'"poxic SHOCK syndrome (TSS) is an acute
illness characterized by the abrupt onset
of fever, headache, gastrointestinal symptoms
and a characteristic erythematous rash which
invariably progresses to desquamation one to
two weeks later. 1 As the name implies, profound
hypotension with consequent oliguria are promi-
nent features, often requiring intensive intra-
venous therapy and occasionally dialysis. 7,8
TSS is now recognized as a unique disease
occurring almost exclusively in women who are
using tampons. 2 4 Epidemiologic studies suggest
that the causative agent is a toxinogenic strain
of coagulase-positive staphylococcus aureus
(CPS) which has been recovered from the
vaginas of the majority of patients. 5,6
We report the following case of TSS in which
the early administration of intravenous nafcillin
sodium ( Nafcil I markedly reduced the severity
of the illness. The accepted criteria for establish-
ing the diagnosis of TSS were not initially met
by our patient, thus necessitating a high index
of suspicion in order to initiate appropriate
therapy.
Case Report
A 22-year-old, white, female college student
reported to the emergency room at Jefferson
Memorial Hospital on March 11, 1982. following
a syncopal episode. The patient had been ex-
periencing headache, fever, nausea and vomit-
ing, and diarrhea for 12 hours. She had seen
the school nurse on two occasions and was given
acetaminophen ( Tylenol l for the fever and
kaolin-pectin I Kaopectate ) for the diarrhea.
The patient had an episode of orthostatic
syncope in her dormitory and was brought to
the emergency room.
On further questioning the patient noted that
she had been on her menstrual period for the
past week and that she was using tampons
( Playtex Super-absorbent). She also recalled
having had an infected hair follicle on her right
thigh prior to the onset of her period. The
patient denied any prior history of menstrual-
related illness, and was on no medications other
than those mentioned.
On physical examination the patient appeared
ill but was alert and well-oriented. Temperature
was 100 6 degrees Farenheit; pulse, 88; blood
pressure. 102/70 supine and 98/70 sitting, and
respiratory rate, 20. The skin was warm and
dry. There was a diffuse erythroderma of the
face and chest suggestive of a mild sunburn.
The conjunctiva were inflamed but without
exudate, and the pharynx was normal-appearing.
There was no adenopathy. The lungs were clear
to auscultation and the heart sounds were
normal. The abdomen was soft with active
bowel sounds and no tenderness or guarding.
A pelvic examination was performed, the
tampon removed and vaginal cultures obtained.
There was a scant white discharge with no bleed-
ing from the cervical os. The uterus and adnexa
were normal. A thorough search for the reported
infected hair follicle was negative.
Laboratory studies obtained on admission in-
cluded urinalysis with s.g. 1.020. pH 5.0, 34-
glucose, 24~ acetone and six to eight white blood
cells per high-power field. Hemoglobin was
13.6 g d 1 with hematocrit of 40.3 per cent. The
white blood cell count was 10.400 with 92 per
cent neutrophils, five per cent bands and three
per cent lymphocytes. Blood urea nitrogen was
14 mg/dl, serum glucose, 120 mg/dl, and
amylase, 45 mg/dl. Serum electrolytes were as
follows: sodium, 143; potassium, 3.8; chloride,
100, and bicarbonate, 25(mEq/L). Gram stain
of the vaginal fluid revealed mixed flora and
few polymorphonuclear cells. Cultures of blood,
urine and pharynx were taken during the initial
examination.
52
The West Virginia Medical Journal
Hospital Course
The presumptive diagnosis of Toxic Shock
syndrome was made and the patient admitted to
the intensive care unit. She was treated with
nafcillin sodium one gram intravenously every
four hours, as well as rapid infusion of five-
per cent dextrose in normal saline. During the
first eight hours, total urine output was only
325 ml.
The patient became afebrile on the second
hospital day with urine output returning to
normal. At this time she had developed edema
of the face, hands and feet, and was complaining
of paresthesias of the hands, but was otherwise
markedly improved.
Cultures of blood and urine were negative on
the third hospital day, and the pharyngeal
culture was negative for group A streptococcus.
Vaginal cultures obtained on admission yielded
a heavy growth of coagulase-positive staphylo-
coccus aureus. The patient was placed on oral
cloxacillin I Tegopen l and was discharged on
the morning of the fourth hospital day.
Two weeks following the onset of illness the
patient developed large-flake desquamation of
fingers, palms and soles. The paresthesias had
completely resolved. Subsequent vaginal cultures
were negative for CPS on two occasions. The
patient has completely discontinued the use of
TABLE
Toxic-Shock Syndrome Case Definition
1. Fever (temperature >38.9 C (102 F)).
2. Rash (diffuse macular erythroderma).
3. Desquamation, 1-2 weeks after onset, particularly
palms and soles.
4. Hsqjotension (systolic blood pressure <90 mm Hg.)
or orthostatic syncope.
5. Involvement of three or more of the following organ
systems:
A. Gastrointestinal (vomiting or diarrhea).
B. Muscular (severe myalgia).
C. Mucous membrane (vaginal, oral, or conjunc-
tival hypermia).
D. Renal (BUN or Cr > 2 x ULN or > 5 white
blood cells per high-power field).
E. Hepatic (total bilirubin, SGOT, or SGPT > 2 x
ULN).
F. Hematologic (platelets < 100,000/mm 1 2 3 ).
G. CNS (disorientation or alterations of conscious-
ness).
6. Negative results on the following tests, if obtained:
A. Blood, throat, urine, or cerebrospinal fluid cul-
tures.
B. Serologic tests for Rocky Mountain Spotted
Fever, leptospirosis, or measles.
tampons, and has had two normal menstrual
periods as of this writing.
Discussion
Todd first described TSS as a new entity in
1978. 1 TSS was distinguished from Kawasaki
disease by its predilection for older children
1 8- 1 7y o I and its unique association with
phage-group-I CPS. A specific exotoxin pro-
duced by the CPS was felt to be responsible for
the multi-system involvement as well as the
characteristic desquamating erythroderma.
The Center for Disease Control ( CDC ) issued
a bulletin in 1980 announcing the high pre-
valence of TSS in menstruating women. 2 CPS
were cultured from 73 per cent of cases, and
the overall case-fatality ratio was then as high
as 15 per cent. Subsequent CDC reports issued
warnings that the use of specific brands of
tampons put these women at high risk for
TSS. 3,4 Later reports, however, proved no
brand-specific association. 3,6 The table lists the
criteria for case definition of TSS as issued by
the CDC. 3 *
The present case is of interest for several
reasons. First, our patient presented in a more
subtle manner than the majority of cases re-
ported in the early series. 5 8 This may be due
in part to the fact that we saw the patient within
the first 12 hours from the time of onset, whereas
most cases reported were seen on the second
day. 10 A high index of suspicion led us to make
an earlier diagnosis than would be allowed by
the currently accepted criteria. Recently, other
investigators have suggested that more liberal
criteria might aid in the earlier recognition of
TSS. 11
A second unusual feature of the present case
was the development of paresthesias of the
hands. This has been previously reported. 10
Other reported sequelae to TSS have included
renal failure, laryngeal paralysis, adult respira-
tory distress syndrome, alopecia, and recurrent
episodes of TSS during subsequent menstrual
periods. 5
Pathway of Infection
A third point of interest in our patient was
the reported infected hair follicle. Although
we were unable to document this on physical
examination, it does bear out one theory as to
the pathway of infection in these patients:
supposed innoculation of the vagina with CPS
through the insertion of contaminated tampons. 9
Our patient must certainly have done this, as
the temporal relationship between the discovery
March, 1983, Vol. 79, No. 3
53
of the furuncle and the onset of TSS was less
than one week.
We began treatment initially with intravenous
nafcillin sodium specifically directed at the
suspected CPS colonization of the vagina. This
course of therapy has been proved to be
efficacious by other investigators. 3,5,9 The use
of beta-lactamase-resistant antibiotics has re-
duced the relapse rate in most series. As of
this writing, our patient has had two normal
menstrual periods without relapse.
Conclusion
We have presented a case of Toxic Shock
syndrome with some unusual features, the most
notable of which was a lack of severity usually
associated with this disease. Our patient was
treated specifically with intravenous nafcillin
sodium, and had a rapid recovery with no
permanent sequelae and no relapses of TSS.
We suggest that more liberal criteria be used
to define TSS in order to allow earlier treatment
with specific antibiotic therapy as well as general
supportive measures.
Acknowledgements
We would like to thank Loretta E. Haddy,
State Epidemiologist with the West Virginia De-
partment of Health, for her assistance in this
case report.
Editor's Note: Here are the generic drugs
and trade names (in parentheses) to which
reference is made in this manuscript: nafcillin
sodium (Nafcil), acetaminophen (Tylenol),
kalin-pectin \ Kaopectate ) , and cloxacillin
( Tegopen ) .
References
1. Todd J, Fishaut M, Kapral F, Welch T: Toxic-
shock syndrome associated with phage-group-I staphy-
lococci. Lancet 1978; 2:1116-8.
2. Morbidity and Mortality Weekly Report. May 23,
1980; 29(20): 229-30.
3. Morbidity and Mortality Weekly Report. Sept. 19,
1980; 29(37):441-4.
4. Morbidity and Mortality Weekly Report. Jan. 30,
1981; 30(3); 25-33.
5. Davis J, Chesney P, Wand P, LeVenture M: Toxic-
shock syndrome: Epidemiologic features, recurrence,
risk factors, and prevention. N Engl J Med 1980; 303
(25): 1429-35.
6. Shands K. Schmid G, Dan B, Blum D, Guidotti R,
Flargrett X, Anderson R, Hill D, Broome C, Band J,
Fraser D: Toxic shock syndrome in menstruating women:
Association with tampon use and stayhylococcus aureus
and clinical features in 52 cases. N Engl J Med 1980;
303(25): 1436-42.
7. Totte R. Williams D: Toxic shock syndrome.
Clinical and laboratory features in 15 patients. Ann Intern
Med 94(2): 149-56.
8. Fisher R. Goodpasture PI, Peterie J, Voth D: Toxic
shock syndrome in menstruating women. Ann Intern
Med 1981; 94(2): 156-63.
9. Shands K, Dan B, Schmid G: Toxic shock syn-
drome: The emerging picture (editorial). Ann Intern
Med 1981; 94(2):264-6.
10. Chesney P, Davis J, Purdy W, Wand P, Chesney
R: Clinical manifestations of toxic shock svndrome.
JAMA 1981; 246(7):741-8.
11. Tofte R. Williams D: Toxic shock syndrome.
Evidence of a broad clinical spectrum. JAMA 1981;
246(19):2163-7.
54
The West Virginia Medical Journal
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THIS ONE’S FOR YOU . . .
'"piMES are tough in West Virginia. The
economic crunch has hit. Our unemployment
rate is one of the highest, if not the highest, in
the nation, and for a great many of these people,
their health benefits are running out. The De-
partment of Welfare is attempting to avoid cuts
in medical services, but because of other budget
cuts is forced to cut almost all social services
contracts. The state Public Employees’ Insurance
Board I responsible for the health benefits pay-
ments of some 94,000 public employees I is
projecting a deficit of at least $9 million for
fiscal year 1983. The Chief Justice of the
Supreme Court has issued an appeal for contri-
butions to a food fund to provide food for needy
families. The doleful litany of economic hard-
ships continues.
In my travels throughout the state on your
behalf, one of the bright spots in this bleak
economic landscape I have found is the en-
couraging number of our physicians who are
contributing their time and talents for little or
no remuneration. Many are not sending in
Medicaid claims. Others are writing off bills for
families in severe economic circumstances, or
arranging long-term deferred payments. The
doctors volunteering for the Handicapped
Children’s Services program devote their time
far in excess of what they would usually expect
to receive. These doctors generally do not get
any kind of credit or publicity for their actions.
This is a form of “good news,” and good news
does not sell newspapers or get media attention
to the extent that had news does.
Obviously, not all our members can participate
in these actions. In areas where practices are
comprised of 40-50 per cent of publically-
assisted patients, the income from the state may
he the difference between keeping the office or
clinic open or shutting it down. Certain areas of
our state, unfortunately, have more than their
share of the medically-indigent population, and
doctors in these areas must utilize all revenue
sources. I understand this and commend them
for their provision of quality medical care with
less than optimum resources.
The generosity of our physicians who are
sharing the burden of the economic times with
their patients is praiseworthy and appreci-
ated. I would urge you to consider, where
appropriate, extending and enlarging this gener-
osity, to insure that those who need quality
medical care are not hampered in their efforts
to achieve it by the fear of inability to pay. I
am not aware of any instance where someone
who truly needed care was turned away purely
because of an inability to pay for it.
So. I personally ask all of you who have not
considered this before to give it your immediate
attention. And, for the many of you who have
been doing this all along; who have been pro-
viding quality medical care at a considerable
sacrifice of your time and talents: and who have
been largely unsung and unpublicized for all this
time, my hat is off to you. As the song says,
friends, “This One’s For You!
d
Harry Shannon, M. D., President
West Virginia State Medical Association
56
The West Virginia Medical Journal
The West Virginia Medical Journal
Editorials
The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or
in communications submitted to this Journal for publication. The author shall be held entirely responsible.
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State
Medical Association
Conservative estimates place costs of “de-
fensive medicine” at 30 per cent of total medical
care costs. Figures such as these are generally
marshaled in any effort to lay at the feet of
physicians blame for the towering costs of
medical care.
Since these costs are generated for purposes
of defending the physician from allegations of
negligence, one is to infer that
RIGOROUS the v are not only unnecessary but
STANDARDS even self-serving and selfishly
motivated.
It is an attractive argument and one most
often enthusiastically received by an audience
primed to damn Medicine and physicians at any
opportunity. The logic of the argument, how-
ever, escapes detection in any serious examina-
tion of the proposition.
If one can accept the assumption that some
serious jeopardy faces the physician if he is,
in fact, found negligent, what then is it in the
field of negligence against w r hich he seeks to
defend himself via extraordinary diagnostic
studies? The answer to this is, of course, that
the physician seeks to defend himself against
charges of negligence for failing to uncover a
rare disease or one totally unrelated to the
complaints and symptoms of concern bringing
that patient to the physician in the first place.
The standard against w 7 hich a physician’s per-
formance is measured has been escalated to
rigorous levels. If a patient visits a physician,
complains of and is treated for an upper
respiratory infection and turns up a month or
tw T o later with carcinoma of the pancreas, the
physician could be found negligent for failing
to diagnose the occult condition. The visit of
any new patient or any old patient not recently
seen thus becomes an occasion demanding a
sophisticated, time-consuming and very expen-
sive workup.
With the physician subject to such a standard
it is remarkable that rises in medical care costs
have been so moderate. The control of these
costs so far demonstrated can only have been
accomplished at the expense of major risks taken
by physicians willing to dare the avarice and
cupidity of predatory plaintiff's attorneys.
The impossible standard is not one set by
Medicine. It is set. of course, by the courts,
aided, abetted, promoted and encouraged by
some members of the legal profession whose zeal
to protect patients is exceeded only by that they
display for fattening their own w 7 allets.
Who, then, is responsible for the costs at-
tributed to defensive medicine — the physician
for using common sense and decent judgment
in defending himself, or plaintiff’s attorneys and
the courts for promoting and tolerating the
imposition of impossible standards?
The West Virginia State Medical Association
has prepared for introduction into this session of
the Legislature bills to effect changes in tort law
which will have the effect of moderating the risks
involved in violating the most onerous provisions
of the impossible medical negligence standard
presently being applied. Those citizens and
particularly those legislators with any serious
intent to help hold down further rises in medical
care costs should examine these bills closely.
The idea of prospective reimbursement has
been getting considerable attention — and has
been tried in several states — as a possible na-
tional dollar-saving solution to the upward trend
in health care costs.
Such systems function in a generally similar
fashion. A rate-setting body determines pay-
ments in advance for services,
SAVE NOW, cases or diagnoses. Individual
PAY LATER? hospital patients, or their in-
surance carriers, must pay those
rates when admitted to a hospital, regardless of
length of stay.
Hospitals may either profit, if patients are
discharged early; break even; or lose, if patients
are hospitalized longer than the predetermined
length of stay.
David A. Smith, M. D., Medical Editor for
Pennsylvania Medicine , has expressed some
March, 1983, Vol. 79, No. 3
57
thoughts about prospective reimbursement as
1982 Medicare amendments have mandated the
development of such a program for 1983 con-
gressional consideration. Here are his views:
‘'If a prospective reimbursement program be-
comes a national reality within the next few
years, as it appears that it may, there are three
areas in which physicians should be prepared
to respond. The first is quality of care. What
will be the effect? Will hospital costs be con-
sidered before quality, and will cost overrule
quality?
“The second is malpractice. Will the standards
that are developed for reimbursement be used
as evidence in malpractice cases? That is, if a
physician releases a patient from the hospital
sooner than the average length of stay de-
termined for the standard, will vulnerability be
increased?
“Third is the continued development of medi-
cine and medical care. Scientific research will
be wasted if the new technologies cannot be ap-
plied to patient care. Will better equipment and
new services become an unaffordable luxury as
prospective reimbursement programs reduce
payment percentages in the name of cost con-
tainment?
“While prospective reimbursement programs
have been touted as the only regulatory
mechanism showing progress in curbing the rise
in health costs, we must not be mesmerized by
the dollar savings in the short term. The long-
term costs of these programs in terms of en-
forced acceptance through cost constraints of
less than top quality medical care may be far
more expensive than our present, less-than-per-
fect, system.
“Like the television commercial suggests, ‘you
can pay me now or pay me later.’ It implies that
skimping now probably will be a lot more ex-
pensive in the long run.”
The dramatic medical breakthrough in the
Barney Clark case — the successful implantation
of a permanent artificial heart in a human
patient — illustrates once again the amazing
strides being made in medical technology.
It also gives pause to thoughtful individuals
as they consider the long-range
ON THE implications of this latest example
ARTIFICIAL of progress.
HEART Obviously, many years and much
more testing will be required
before the artificial heart will be available to aid
patients on a widespread basis. Eventually,
however, its widespread use seems likely.
The unanswered question is cost. Consider
this example: In 1972, Congress approved
coverage of renal dialysis for Medicare patients,
with an estimated cost of about $250 million
per year. For 1983, the estimated cost is more
than $2 billion. The cost of the artificial heart
device alone is more than $16,000. That figure
is exclusive of all other costs. Any estimate of
the cost of widespread use of this technique
would be mere speculation.
The artificial heart illustrates the capability of
today's technology and of its brilliant scientists.
Similar dramatic progress is inevitable in other
fields.
Can society afford to make this wonderful new
technology available to every patient who needs
it? If not, who shall decide which patients do
receive it? Medicine and society must make
some agonizing decisions in the future. - —
American Medical News, December 17, 1982.
The above editorial addresses the problem of
cost of implantation of the artificial heart. Cost
is not the only “unanswered question. ’ The
heart is the only organ in the body that has one
function: it is a simple pump. Between one-
third and one-half of Americans succumb to
heart attack or heart fail-
MORE ON THE ure as a result of damage
ARTIFICIAL HEART to this pump. It seems
likely that the technical
problems that occurred with Barney Clark’s
artificial heart will soon be corrected and per-
fected. In the foreseeable future a model which
can function indefinitely may be available.
We can speculate that in time implantation of
an artificial heart could prolong the lives of
countless thousands, perhaps millions, of Ameri-
cans. Approximately 15 to 20 per cent of people
over the age of 70 now suffer from chronic
dementia requiring custodial or home care by
other individuals. This could double in the
next 10 to 20 years. It is not likely that artificial
livers, lungs, and kidneys — much less brains —
are on the horizon.
Adding to life expectancy with artificial
hearts, without prospect of any means of revers-
ing the natural aging process, could greatly in-
crease the number of demented people. Hearts
that keep on beating and pumping blood to
organs that continue to wear normally may
create new problems for society.
This is not just a problem of medical cost, but
one of deeper social and ethical significance.
58
The West Virginia Medical Journal
GENERAL NEWS
AMA President To Speak
At Annual Meeting
Dr. Frank J. Jirka. Jr., M. D., who will be
installed as President of the American Medical
Association in Chicago in June, will speak
during the State Medical Association’s 116th
Annual Meeting in August. Doctor Jirka, a
urologist practicing in Barrington and Berwyn,
Illinois, will address the first session of the
House of Delegates Thursday afternoon. August
25.
The convention will be held August 25-27 at
the Greenbrier in White Sulphur Springs. It will
open with a pre-convention session of the As-
sociation’s Council and the first House session
on Thursday morning and afternoon; and end
with the second and final House session and
reception for new Association officers on Satur-
day afternoon and evening.
Long active in organized medicine. Doctor
Jirka was first elected to the AMA Board of
Trustees in 1974. He served as its Secretary
in 1976-77 and as its Vice Chairman from 1977
to 1979. Doctor Jirka has served the Illinois
State Medical Society as its President. Chairman
of the Board of Trustees, and as a Delegate to
the AMA House of Delegates. Currently, he is
a Councilor of the Chicago Medical Society.
M. D. from University of Illinois
Born in Illinois, Doctor Jirka attended Knox
College in Galesburg, Illinois, before entering
the University of Illinois College of Medicine
where he received his M. D. degree in 1950.
He served his internship and residency at Cook
County Hospital. Chicago, from 1950-54. Doctor
Jirka is a Diplomate of the American Board of
L T rology, and a Fellow of the American College of
Surgeons and the International College of
Surgeons.
Motivated by severe injuries sustained as a
Navy frogman during World War II, resulting
in the amputation of both his legs below the
knee, Doctor Jirka has devoted a great deal of
his time toward rehabilitation programs. He has
served on the President’s and the Governor’s
Committees on Employment of the Handicapped,
and has been a Board member of the Illinois
Association of Crippled Children as well as the
Illinois Rehabilitation Association.
Doctor Jirka is a Clinical Associate Professor
in LTology at Loyola University Stritch School
of Medicine, a Consultant in Llrologv at Hines
Veterans Administration Hospital, and formerly
was an Associate Professor in LTrology at Cook
County Graduate School of Medicine.
Doctor Jirka and his wife, Pat. have three
daughters, Lynn J. Sutherland, Mary Pat. and
Ella Kay.
Scientific Sessions
The initial general scientific session, as an-
nounced earlier, will be a symposium on sexually
transmitted diseases. It will be held at 9:45
A. M. on Friday, August 26, preceded by the
traditional opening exercises. A keynote speaker
for the latter program will be announced later
by the Annual Meeting Program Committee.
David Z. M organ, M. D., of Morgantown, the
Program Committee Chairman, said the first
Frank J. Jirka, Jr., M. D.
March, 1983, Vol. 79, No. 3
59
scientific session Friday morning will include
papers on these individual topics:
Syphilis and gonococcal infections; non-luetic,
non-gonococcal venereal diseases; transmissible
diseases of the gay patient, and sexual mores in
the 1980s.
The second general scientific session will be
held Saturday morning, August 27 and, also as
announced previously, will be a symposium on
cardiovascular diseases. The Saturday morning
topics will include new developments in the
management of cardiac arrhythmias; an update
relative to cardiovascular surgery, and the
management of congestive heart failure.
Specialty Groups
In addition to the general sessions, the Annual
Meeting agenda will include breakfast, luncheon
and other programs arranged by specialty
societies and sections, many of which also will
provide scientific discussions.
The specialty group meetings will be held in
large measure on Friday, with a few to be set
for Saturday morning, preceding the second
general session, and at noon.
At the final House session on Saturday after-
noon, Carl R. Adkins, M. 1)., of Oak Hill will be
installed as the Association’s 1983-84 President
to succeed Harrv Shannon, M. D., of Parkers-
burg.
Continuing a practice of many years, the
Auxiliary to the State Medical Association, with
Mrs. Richard S. Kerr of Morgantown the cur-
rent President, will hold its meeting in con-
junction with that of the Association.
Serving with Doctor Morgan on the 1983
Program Committee are Doctor Adkins: Jean P.
Cavender. M. D., Charleston; Michael J. Lewis,
M. I)., St. Marys; Kenneth Scher, M. D..
Huntington, and Roland J. Weisser. Jr., M. D.,
Morgantown.
Additional information concerning speakers
and other convention details will he provided
in upcoming issues of The Journal.
Infection Control, Tumors
CME Program Topics
An Infection Control Workshop and Sym-
posium on Tumors will be among continuing
medical education programs offered by West
Virginia University School of Medicine and
other sponsors in March.
The Infection Control Workshop will be held
Friday afternoon and Saturday morning. March
25-26, at Lakeview Inn in Morgantown. The
Program Director will be R. Brooks Gainer II.
M. I)., WVU Clinical Associate Professor, Sec-
tion of Infectious Diseases, and Chairman, In-
fection Control Committee, Monongalia General
Hospital, Morgantown. The WVU Department
of Medicine, Section of Infectious Diseases, and
the hospital are the sponsors.
The Symposium on Tumors, designed to pro-
vide the practicing orthopedic surgeon with a
Some 250 physicians and others attended the 16th Mid-Winter Clinical Conference in Charleston
January 21-23 under the sponsorship of the State Medical Association and the West Virginia University
and Marshall University Schools of Medicine. In the left photo, conference material is examined by Drs.
Joseph T. Skaggs (left) of Charleston, Chairman of the Program Committee, and Harry Shannon, Parkers-
burg, Association President. On the right are two of the Friday afternoon, January 21, speakers, Drs. Jack
M. Bernstein (left), Huntington, and Larry I. Lutwick, Brooklyn, New York.
60
The West Virginia Medical Journal
perspective regarding the treatment of bone
tumors within the community hospital setting,
is scheduled for March 28-29 at the Greenbrier
in White Sulphur Springs.
Material, to be presented entirely by the case
method, will cover metastatic lesions, benign
tumors of the bone, malignant tumors, and
segmental resection.
Tumor Symposium Faculty
Members of the faculty will be Drs. William
Enneking, Distinguished Service Professor of
Orthopedic Surgery, University of Florida:
Henry J. Mankin, Edith M. Ashley Professor
of Orthopedic Surgery, Harvard Medical School,
and Chief of Orthopedics, Massachusetts General
Hospital, Boston; John Murray, Clinical As-
sociate Professor of Orthopedics, Baylor College
of Medicine and University of Texas at Houston,
and Chief of Orthopedics, M. D. Anderson
Hospital and Tumor Institute, Houston;
Douglas Pritchard, Head of Section. Ortho-
pedic Oncology, Mayo Clinic, and Associate Pro-
fessor, Mayo Medical School; Eric L. Radin.
WVU Professor and Chairman, Orthopedic
Surgery; Allan Schiller. Associate Professor.
Pathology. Harvard Medical School and Massa-
chusetts General Hospital; and Jamshid Tehran-
zadeh, WVU Assistant Professor of Radiology
and Chief. Bone Radiology Section.
Sponsors are the WVU Department of
Orthopedic Surgery and Office of Continuing
Medical Education.
Infection Workshop Speakers
Speakers and topics for the infection work-
shop will be: “Making Infection Control
Applicable to the Patient” — Sue Crow, R.N.,
M.S.N., Nurse Epidemiologist, Louisiana State
University; “Herpes Simplex — Impact on Pa-
tient and Staff” — Robert Belshe, M. D., MU As-
sociate Professor of Medicine and Microbiology,
Section of Infectious Diseases; “Hepatitis B
Vaccine — AIDS” — C. Glen Mayhall, M. D.,
Associate Professor of Medicine, Medical Col-
lege of Virginia; “Infections of Surgical Patients
and Prevention of Surgical Infections” — Ronald
Nichols, VI. D., Professor of Microbiology and
Immunology, Department of Surgery, Tulane
L niversity;
“Influenza and Influenza Vaccines" — Robert
Waldman. M. D., Professor of Medicine and
Interim Dean. WVU School of Medicine;
“Hospital-Acquired Pneumonia” — Ronica Kluge,
M. D., Professor of Medicine, University of
Texas Medical Branch. Department of Medi-
cine, Galveston: “Tuberculosis in the Hospital"
— Rashida Khakoo, M. D.. WVU Associate Pro-
fessor of Medicine, Division of Infectious
Diseases;
California Speaker
"Infections in the Compromised and Im-
munosuppressed Patient" — Lowell Young, M. D.,
Professor of Medicine, Division of Infectious
Diseases, University of Southern California, Los
Shown in the left photo is Gary A. Banas (center), Akron (Ohio) attorney, speaker for the Physicians’
Session of the 16th Mid-Winter Clinical Conference held in January in Charleston. The session was
entitled, “The Doctor, Quality Control and Professional Liability.” With Banas are John F. Wood (left),
Huntington attorney, and Dr. Jack Leckie, also of Huntington, panelists. On the right are panelists Tom
Auman (left), Director of Professional Liability, McDonough Caperton Shepherd Association Group, Charles-
ton: and attorney Fred Bockstahler, Director of Patient Affairs, Charleston Area Medical Center. Not
shown is panelist James C. Crews, CAMC President.
March, 1983, Vol. 79, No. 3
61
Angeles; "In-Hospital Staphylcoccal Infections”
— Chatrchai Watanakunakorn, M. D., Professor
of Internal Medicine, College of Medicine,
Northeastern Ohio University; and “Current
Concepts of the Pathogenesis and Rational
Measures for Prevention of Infection due to
Intravascular Devices” — Dennis G. Maki, M. D.,
Professor of Medicine, Section of Infectious
Diseases, University of Wisconsin.
For registration and additional information
concerning either meeting, telephone the WVU
Office of Continuing Medical Education at
(304) 293-3937.
Chapter Plans 16 Papers
For April Meeting
“Recent Advances in Treatment of Headaches
in Children ’ will be among some 16 papers to
be presented during the 31st annual scientific
assembly of the West Virginia Chapter, Ameri-
can Academy of Family Physicians.
The meeting will be held April 15-17 in
Morgantown at the Lakeview Inn and Country
Club.
The talk on headaches in children will be
given Sunday morning, April 17, by Arnold D.
Rothner, M. D., Chief, Section of Child
Neurology, The Cleveland Clinic Foundation.
In addition to the concluding Sunday morn-
ing session, scientific sessions also will be held
Friday morning and afternoon, and Saturday
morning and afternoon.
Senile Dementia
Some of the other speakers will be James
T. Hartford, M. D., Associate Professor and
Chief, Geriatric Psychiatry, University of
Cincinnati Medical Center, on “Senile Dementia"
(Sunday morning); Thomas Roth, Ph.D.,
Arnold D. Rothner, M. D. James T. Hartford, M. D.
Thomas Roth, Ph.D.
Joseph M. Pitone, D. O.
Director, Sleep Disorders and Research Center,
Henry Ford Hospital, Detroit, “Now I Lay Me
Down to Sleep . . . Insomnia" (Saturday morn-
ing); and Joseph M. Pitone, D.O., Assistant
Professor of Medicine, Department of Nephro-
logy and Hypertension, University of Medicine
and Dentistry of New Jersey, New Jersey School
of Osteopathic Medicine; and Head, Subsection,
Department of Nephrology and Hypertension,
John F. Kennedy Memorial Hospital, Stratford
I New Jersey) Division. "Hypertension Treat-
ment for Family Physicians" (Saturday after-
noon I .
Other subjects to be discussed will include
physician exercise and fitness; the impaired
physician; office management; peptic ulcer
disease: low back pain; beta blockers; throm-
bolytic therapy in venous thromboembolic
disease; and rheumatology.
I See story in the February issue of The
Journal for a complete list of speakers and
topics. )
The program is acceptable for 18 and one-
half Prescribed hours by the AAFP, and is
approved for the same number of hours in
Category 1 of the Physician's Recognition Award
of the American Medical Association.
Other Activities
The Chapter’s House of Delegates will hold
a noon luncheon meeting on Friday, and the
Board of Directors will meet at 6 P. M. Thurs-
day, April 14, and 1 P. M. Sunday. The annual
banquet session is scheduled for 7:30 P. M.
Saturday.
A breakfast meeting at 7 o’clock Sunday will
be held by the Board of Directors of the Family
Medicine Foundation of West Virginia.
Family Physicians will be welcomed to the
scientific assembly by Dr. Robert D. Hess of
Clarksburg, President.
62
The West Virginia Medical Journal
WVU Charleston Geriatric
Program March 16
Geriatric Update '83. a half-day continuing
medical education program, will be held in
Charleston on Wednesday afternoon. March 16.
The meeting site will be the West Virginia
University Medical Center Education Building
at 3110 MacCorkle Avenue, S.E.
By attending this program, participants will
be able to determine effective usages of drugs
and multiple drugs in care of the elderly patient,
identify depressive states in the elderly, and
understand current concepts in sleep patterns in
the aged patient.
Faculty members will be: Mary Beth Gross,
Pharm. D., Assistant Professor of Clinical
Pharmacy, WVU Charleston Division; Albert
Heck, M. D., Clinical Associate Professor of
Neurology, WVU Charleston Division: Donald
S. Robinson, M. D., Chairman, Department of
Pharmacology, and Professor of Pharmacology
and Medicine, Marshall University School of
Medicine; and Thomas Roth, Ph.D.. Director,
Sleep Disorders and Research Center, Henry
Ford Hospital, Detroit.
The program is approved for four credit hours
in Category 1 of the Physician’s Recognition
Award of the American Medical Association.
For additional information contact WVU
Conference Services at (304) 347-1242.
Continuing Education
Activities
Here are the continuing medical education
activities listed primarily by tbe West Virginia
University School of Medicine for part of
1983, as compiled by Dr. Robert F. Smith,
Assistant Dean for Continuing Education, and
J. Zeb Wright, Ph. D., Coordinator, Con-
tinuing Education. Department of Community
Medicine, Charleston Division. The schedule is
presented as a convenience for physicians in plan-
ning their continuing education program. (Other
national, state and district medical meetings are
listed in the Medical Meetings Department of
The Journal. )
The program is tentative and subject to
change. It should be noted that weekly confer-
ences also are held on the Morgantown, Charles-
ton and Wheeling campuses. Further information
about these may be obtained from: Division of
Continuing Education. WVU Medical Center,
3110 MacCorkle Avenue, S. E., Charleston
25304: Office of Continuing Medical Education,
WVU Medical Center, Morgantown 26506; or
Office of Continuing Medical Education. Wheel-
ing Division. WVU School of Medicine, Ohio
V alley Medical Center. 2000 Eoflf Street, Wheel-
ing 26003.
(continued on next page)
Shown in the left photo are, from left, Drs. Tony C. Majestro, Charleston orthopedic surgeon, and Frank
C. McCue III of Charlottesville, Virginia, who spoke to physicians on sports medicine during the recent
Mid-Winter Clinical Conference in Charleston. Doctor McCue also was the speaker for the Friday evening
public session on medical care for the athlete. Doctor Majestro presided at the public session. On the
right. Dr. James W. Kessel (left) of Charleston, speaker on trauma transport, chats with Dr. and Mrs.
J. C. Huffman of Buckhannon.
March, 1983, Vol. 79, No. 3
63
March 16, Charleston, Geriatric l pdate ’83
March 18, Charleston. 10th Annual Newborn
Day
March 25-26, Morgantown. Infection Control
Workshop
March 28-29. White Sulphur Springs, Sym-
posium on Tumors for the Orthopedic
Surgeon
April 28, Wheeling, Balance Disorders
April 29, Charleston, Research Day
April 29-30. Morgantown, Orthopedic Reunion
Days
May 7, Charleston, Outpatient Infectious Dis-
eases
May 12-13. Morgantown, Health Officers Con-
ference
June 3-4, Morgantown, Anesthesia Update ’83
June 4, Charleston, 10th Annual Wildwater
Conference — Medical & Surgical Update
Regularly Scheduled Continuing
Education Outreach Programs from
WVU Medical Center/
Charleston Division
Buekhannon , St. Joseph’s Hospital, first-floor
cafeteria, 3rd Thursday, 7-9 P. M. — March
17, “Thyroid Dysfunction: Diagnosis and
Management,' Richard Kleinmann, M. D.
April 21, “Prenatal Disorders and Congenital
Anomalies,” R. Stephen S. Amato. M. D.
May 19, “Evaluation of Infertility and Fre-
quent Spontaneous Abortions,” Bruce U.
Berry, M. D.
Cabin Creek, Cabin Creek Medical Center,
Dawes, 2nd Wednesday, 8-10 A. M. — March
9, “Overall Outpatient Management of Renal
Dysfunctions,” Mary Uou Lewis, M. D.
Cassaway, Braxton Co. Memorial Hospital. 1st
Wednesday, 7-9 P. M. — March 2. “Enteral
Alimentation." Brittain Mcjunkin, M. D.
April 6, “Clinical Intervention in Drug &
Alcohol Abuse,” Thomas Haymond, M. D.
Madison, 2nd floor. Lick Creek Social Services
Bldg., 2nd Tuesday, 7-9 P. M. — March 8.
"Drug & Alcohol Abuse: Intervention Strate-
gies," Thomas Haymond, M. 1).
Oak Hill. Oak Hill High School I Oyler Exit, N
19 1 4th Tuesday, 7-9 P. M. — March 22.
“End-Stage Renal Disease,” Mary Lou Lewis,
M. D.
April 26. “Adolescent Sexuality: Recognizing
& Treating Pathological Behavior.” T. 0.
Dickey, M. D.
Welch, Stevens Clinic Hospital. 3rd Wednesday,
12 Noon-2 P. M. — March 16. “Protocols
for Treating Poisonous Snake Bites. ’ David
O. Wright, M. D.
April 20, “Emotional Trauma of Cancer,”
Sr. Frances Kirtley. R.N., and Sue Warren,
M. D.
Whitesville, Raleigh-Boone Medical Center, 4th
Wednesday, 11 A. M.-l P. M. — March 23.
"Hypertension Update: Diagnosis & Manage-
ment," Stephen Grubb. M. D.
April 27, “Obesity: Emotional Factors in
Compliance,” John Linton, Ph.D.
IVilliamson, Appalachian Power Auditorium, 1st
Thursday, 6:30-8:30 P. M. — March 3,
“Suicide Intervention.” Martin Kommor.
M. D.
Review A Book
The following books have been received by the
Headquarters Office of the State Medical Associa-
tion. Medical readers interested in reviewing any
of these volumes should address their requests to
Editor. The West Virginia Medical Journal, Post
Office Box 1031. Charleston 25324. We shall be
happy to send the books to you. and you may
keep them for your personal libraries after sub-
mitting to The Journal a review for publication.
Basic and Clinical Pharmacology, by Bertram
G. Katzung, M. D., Ph.D. 815 pages. Price
$23.50. Lange Medical Publications, Los Altos.
California 94022. 1982.
Nine Months' 1 Reading : A Medical Guide for
Pregnant W omen, 3rd Edition, by Robert E.
Hall, M. D. 178 pages. Price $13.95. Double-
day & Company, Inc., 245 Park Avenue, New
York. New York 10167. 1983.
Living With Herpes, by Deborah P. Langston.
M. I). 198 pages. Price $7.95. Doubleday &
Company, Inc., 245 Park Avenue, New York.
New York 10167. 1983.
64
The West Virginia Medical Journal
Council Acts On Trauma
Centers, Loan Fund
The State Medical Association’s Council, at
its January 16 meeting, endorsed the concept
of designating West Virginia hospitals as trauma
centers, following the criteria of the American
College of Surgeons.
The action was taken following a presentation
by Dr. Frederick M. Cooley of Charleston,
Director. Emergency Medical Services of the
State Health Department.
Doctor Cooley proposed that the State Health
Department be empowered to designate West
\ irginia hospitals as trauma centers following
application by an interested hospital and a site
inspection visit to the hospital.
The Council also unanimously sanctioned
contributions to the Clark K. Sleetli Medical
Speakers for the Saturday afternoon session on pediatric topics during the Mid-Winter Clinical Con-
ference are shown with Dr. Herbert H. Pomerance (second from right) of Charleston, who presided. They
are, from left, Drs. Martin R. Klemperer and Roberta Gray, both of Huntington, and R. Stephen S. Amato
of Morgantown. In the right photo, Dr. Stephen L. Sebert (left) of Fairlea (Greenbrier County), has a
conversation with Dr. William O. McMillan, Jr., of Charleston, member of the Program Committee.
Dr. William H. Nelson of Farmington, Connecticut, a psychiatrist who was a speaker for the Sunday
morning session of the Mid-Winter Clinical Conference, is shown in the left photo. In the right photo,
the other Sunday morning speakers go over the program with Dr. John W. Traubert (center) of Morgan-
town, who presided. They are Drs. Robert C. Touchon, left, Huntington cardiologist, who talked on
calcium channel blockers, and George W. Weinstein, Morgantown ophthalmologist, whose subject was
lens replacement.
March, 1983, Vol. 79, No. 3
65
Student Loan Fund in memory of the late Doctor
Sleeth, former Dean of the West Virginia Uni-
versity School of Medicine, who died last
November. Checks may be made payable to the
“WVU Foundation,” and it is suggested that the
following be written in the lower left corner:
“This contribution for the Clark K. Sleeth Medi-
cal Student Loan Fund.” Checks may be sent
to Dr. David Z. Morgan, Associate Dean of the
WVU School of Medicine, Morgantown 26506.
In other action. Council:
— Heard an update on the Association-
endorsed professional liability insurance pro-
gram with CNA of Chicago as the carrier by Dr.
Jack Leckie of Huntington, Chairman of the As-
sociation's Committee on Insurance.
— Elected to honorary membership, after
appropriate component society action, Dr. Lysle
T. Veach of Petersburg.
—Heard a review by staff members Robert F,
Bible, Staff Counsel, and Charles R. Lewis,
Executive Secretary, of medicine-related legisla-
tion introduced to date in the State Legislature.
— Elected or re-elected the following as
nucleus members of the West Virginia Political
Action Committee Board: Dr. Stephen D. Ward
of Wheeling, First Congressional District; Dr.
John L. Fullmer of Morgantown, Second Con-
gressional District; Dr. Joseph T. Skaggs of
Charleston, Third Congressional District; Dr.
Frank J. Holroyd of Princeton, Fourth Congres-
sional District, and Dr. Thomas F. Scott of
Huntington and Bible as ex officio members
An Open Letter
To West Virginia’s Physicians and Others:
As the years add up, and one gets along in
life, it’s not uncommon for a wheel or two to
come off — sometimes not only unexpectedly,
but in a hurry. That’s what happened to me
in recent weeks.
As members of the Executive Committee,
Council and some others were aware, through
myself, Drs. Carl Hall and John Markey,
discovery of a rectal-area malignancy led very
quickly to a colostomy. The post-operative
prognosis appears at this point (February 6)
most favorable; I’m at home recuperating,
and I feel great.
There is just no way in which I can ever
express to you individually my gratitude for
your prayers; your many cards; flowers;
telephone calls to the hospital, the Association
office and my home; and the visits to the
hospital by a number of physicians and others.
Completely inadequate that it might be,
this message to the members of the Associa-
tion accordingly is the only way I feel I have
of expressing the deep-felt gratitude of my-
self, Jane and all the other members of my
family.
I must confess to a feeling, also, of humble
pride in the concern and interest from every
part of the state and the physician com-
munity. We certainly have always made it our
first order of business, as a state office, to
exert every bit of effort to make the Associa-
tion what its constitution says it shall be — and
1 have new confidence, gained through an
admittedly unexpected channel — that we at
least are headed in a strong and correct
direction.
Under the current circumstances, a renewed
expression of gratitude also is in order for
the other members of the headquarters staff —
Custer Holliday, Bob Bible, Mary Hamilton,
Sue Shanklin, Mary Sue Smalley and Beverly
O’Dell.
As I have often said, excluding my own
12 years with the Association and the Medical
Institute, this staff represents some 60 years
of service, expertise and dedication to the
State Medical Association, its members and
the people of this state. In this day and time,
that kind of situation is virtually unheard of.
Staff was aware in every detail of what I
faced; what my limitations would be for at
least a little while; and some shifting and
increase in workloads. They haven't missed
a beat, with Custer doing his usual super job
with the Mid-Winter Conference and the
others right in step.
I’m proud of, and grateful for, that kind
of support. And by the time you read this, I
expect — with my doctor’s close direction, of
course — to be for the most part back in the
saddle and at least able to handle the major
issues at hand.
God bless you one and all,
Charles R. Lewis
Executive Secretary
66
The West Virginia Medical Journal
representing the Council and the State Medical
Association staff, respectively.
— Approved the payment of round-trip air
fare for a representative to the meeting of the
residents section at the annual meetings of the
American Medical Association ( pending final
approval of a membership category for residents
by the State Association's House of Delegates
at the Annual Meeting next August).
— Approved the transfer of the Association
employee benefit plan from the Connecticut
Mutual Life of Hartford, Connecticut, to the
Kanawha Valley Bank in Charleston.
— Heard comments by Dr. L. Clark Hans-
barger. State Health Director, on the State
Health Department budget, legislation sponsored
by the Department, and the rationale behind the
announced closing of Spencer State Hospital.
— Reconfirmed previous Council action in en-
dorsing a collection service offered by I. C.
System, Inc., of St. Paul, Minnesota.
Pain Killers Underutilized,
AMA President Says
Physicians frequently underutilize pain medi-
cations for terminal patients, American Medical
Association President William Y. Rial, M. D.,
said at a recent AMA conference on severe
chronic pain. Every day, thousands of patients
suffer unnecessarily because a drug is admin-
istered in inadequate doses or excessively long
dosing intervals, he said.
Doctor Rial noted that patients often are
reluctant to reveal the severity of their pain or
to take narcotics. Hospital staffs and relatives
often have a misguided concern that the
terminally ill patient will develop a drug de-
pendence, he said at the Conference on the Care
of Patients with Severe Chronic Pain in
Terminal Illness, which was co-sponsored by the
U.S. Public Health Service.
“It is the responsibility of every physician
and all others who serve patients to understand
the dynamics of pain, to understand the
pharmacologic activity of analgesics, and, most
importantly, to work with and understand the
needs of each patient and the family,” Doctor
Rial said at the conference in Washington, D. C.
The conference coincided with the reintroduc-
tion of a bill by Sen. Daniel Inouye (D, Hawaii)
that would legalize heroin for use in relieving
pain for terminal patients.
“I personally do not believe that legalizing
heroin or making it more available is necessary
March, 1983, Vol. 79, No. 3
for the treatment of patients,” Assistant Secre-
tary for Health Edward N. Brandt, Jr., M. D.,
told the AMA. “The other analgesics that are
on the market are equally potent, and the new
ones that are being developed are up to six times
more potent than heroin.”
Rescheduling heroin would lead to illegal
trafficking and promote drug abuse that can
ruin the lives of children and young adults, said
Doctor Brandt, who was a speaker at the con-
ference.
Clark K. Sleeth Memorial
Started By AAFP
A Clark K. Sleeth, M. D., Memorial Fund
has been established by the West Virginia
Chapter, American Academy of Family Physi-
cians through the Academy’s Family Medicine
Foundation of West Virginia.
The action was taken by the Academy at its
January meeting in Charleston to honor the late
Doctor Sleeth, a former Dean of the West Vir-
ginia University School of Medicine and the
first Chairman of the WVU Department of
Family Practice. Doctor Sleeth died last
November 30.
Proceeds from the memorial fund will be
channeled into the Foundation’s regular pro-
grams, including support for family practice
residency programs, family practice clubs for
undergraduates, and student scholarships.
Checks should be payable to the Family
Medicine Foundation of West Virginia, and sent
to the Foundation at P. 0. Box 7058, Cross
Lanes, Charleston 25313-0058.
AMA Takes Strong Stand
On Drunk Driving
The American Medical Association has noted
its support of incentive grants to states that
voluntarily improve their laws and traffic safety
programs to curtail drunk driving accidents.
Enacted by the last Congress, PL 97-364 will
“encourage and enable the states to increase and
improve their efforts to reduce the number of
drunk drivers on the road,” the AMA said
recently in comments on the advance notice of
proposed rule-making to implement the law.
To be eligible for the supplementary funds,
the states must ( 1 ) suspend the driver’s licence
for at least 90 days on the first conviction, (2)
sentence repeaters to at least 48 hours in jail
or to 10 days’ community service, (3) recognize
67
0.10- per cent blood alcohol concentration as the
legal measure of intoxication, and I 1 ) increase
efforts to enforce alcohol-related traffic laws and
to let the public know of such enforcement.
A state may participate in the program for
a maximum of three years. The federal share
will diminish from 75 per cent in the first year,
to 50 per cent in the second year, and to 25
per cent in the third year. A total of $25 million
has been authorized for fiscal year "83. and $50
million each for fiscal year '84 and fiscal year
'85.
AMA Leader Speaks
‘'Let’s get drunk drivers off the road.” AMA
Executive Vice President James H. Sammons,
M. D., said at a recent meeting of the Alliance
Against Intoxicated Motorists ( AAIM ) in
Chicago. “Drunk drivers are responsible for an
epidemic of tragic human carnage on our roads
and highways,” said the AMA leader, who stated
that about 27.500 Americans are killed and
about 700.000 people are seriously injured in
alcohol-related traffic accidents each year.
“If you visited the emergency room of a
community hospital during the late night or early
morning hours on any Friday or Saturday, when
drunk drivers are most prevalent, you would
probably conclude that our roads and highways
have become a battlefield. In that emergency
room, you would find physicians and other
health professionals desperately trying to save
the maimed victims of a drunken driver."
A featured speaker on the program was
nationally syndicated advice columnist Ann
Landers, who declared that drunken driving is
a “national disgrace.” “We have got to do some-
thing about the judges who keep letting these
guys off.” said Landers, who is a member of the
President's Commission on Drunk Driving. She
supported state efforts to reduce alcohol-related
accidents among young people by raising the
drinking age from 18 to 21 years of age.
Past AMA Action
Through the years, the AMA House of Dele-
gates has taken a number of actions to stop
drunk driving. In 1960, the House recommended
that a blood alcohol level of 0.10 per cent should
he accepted as prima facie evidence of legal in-
toxication. In 1981, it called on state and
specialty societies to seek enactment of more
stringent drunk driving laws in all the states.
At the meeting last December in Miami
Beach, the House directed the AMA to provide
even stronger support for state and federal
legislation.
Medical Meetings
March 4-6 — Am. Medical Student Assoc., Cleevland.
March 5-12, Canadian Am. Medical Dental Assoc.,
Vail, CO.
March 10-15 — Am. Academy of Orthopedic Sur-
geons, Anaheim, CA.
March 20-24 — Am. College of Cardiology, New Or-
leans.
April 7-8 — WV Chapter, Am. Academy of Pediatrics,
Beckley.
April 11-14 — Am. College of Physicians, San
Francisco.
April 15-17 — WV Chapter, AAFP, Morgantown.
April 16-21 — Am. Academy of Pediatrics, Phila-
delphia.
April 17-21 — Am. Urological Assoc., Las Vegas.
April 17-22 — Operative Treatment of Fractures &
Nonunions (Johns Hopkins University), Hot
Springs, VA.
April 18-22 — Am. Roentgen Ray Society, Atlanta.
April 22-24 — Medical Staff Leadership Seminar
(Southern Medical Assoc.), Hilton Head, SC.
April 23 — WV Diabetes Assoc., Charleston.
April 24-28 — Am. Assoc, of Neurological Surgeons,
Washington, D. C.
May 4-7 — WV Chapter, Am. College of Surgeons,
White Sulphur Springs.
May 6-8 — Southern Medical Assoc. Regional Post-
graduate Conference, Lexington, KY.
May 8-12 — Am. College of Obstetricians & Gyne-
cologists, Atlanta.
May 13-14 — Topics in Cardiovascular Diseases (Am.
Heart Assoc.), Baltimore.
May 26-28 — Am. Assoc, of Genitourinary Surgeons,
White Sulphur Springs.
June 19-23 — Annual Meeting of AMA House, Chi-
cago.
Aug. 25-27 — 116th Annual Meeting, VV. Va. State
Medical Assn., White Sulphur Springs.
Sept. 29-Oct. 2 — Am. Society of Internal Medicine,
San Francisco.
Oct. 16-21 — Am. College of Surgeons, Atlanta.
Nov. 6-9 — Scientific Assembly, Southern Medical
Assoc., Baltimore.
68
The West Virginia Medical Journal
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WVU Medical Center
-News—
i
i
Compiled from material furnished by the Medical Center
News Service, Morgantown, W. Vo.
Medical Graduate Return Rate
Above National Average
West Virginia University is returning a good
percentage of its medical graduates to practice
in West Virginia, in numbers better than the
national average, according to Interim Dean
Robert H. Waldman, M. D., of the School of
Medicine.
Doctor Waldman's comments were in response
to concerns, in a time of major state financial
difficulties, over whether the state’s medical
schools are meeting its health manpower needs.
"It makes us very unhappy to hear it said
that West Virginia University is not returning
its medical graduates to West Virginia to
practice medicine,” Doctor Waldman said.
‘Proven Track Record’
“Furthermore, unlike some medical schools,
we are not just talking about our good intentions.
We’re not just planning to produce doctors for
West Virginia; we have a proven track record
of graduates remaining in West Virginia to
practice.”
Doctor Waldman said WVU medical graduates
“are also choosing medical specialties most
widely needed in a rural state such as ours, and
many are practicing in areas of the state that
have been short on doctors.”
Nationwide, less than 40 per cent of all
physicians are practicing in the state where they
received their M. D. degrees. The figure is
even lower among most small states.
“Against these figures, West Virginia Uni-
versity stands up well,” Doctor Waldman said.
“Of the 766 WVU medical students who earned
their M. D. degrees during the 1970s, 41.1 per
cent are practicing in West Virginia.
“The figures look even better when you con-
sider the past five years: except for a slight lag
in 1978, the percentage of our graduates re-
maining in West Virginia has been near 50 per
cent since 1974."
The percentage of West Virginia physicians
who are WVU graduates increased by 89.5
per cent between 1972 and 1982.
WVU graduates who remain in West Virginia
also tend to choose to specialize in the areas
of greatest need. The top five specialties of
WVU medical graduates who are practicing in
West Virginia are internal medicine, family
practice, general surgery, psychiatry, and
obstetrics and gynecology.
Nearly 60 per cent of the WVU medical
graduates who chose family practice or general
practice as their specialty have remained to
practice in West Virginia.
In addition, physicians who do their post-
graduate training at WVU — whether or not they
earned their M. D. degree in West Virginia —
tend to remain in the state.
Doctor Gutmann Serving
On National Board
Uudwig Gutmann. M. D., Chairman of
Neurology, has accepted an invitation to serve
on the National Board of Medical Examiners.
The hoard designs and regularly updates
examinations used in the licensing of physicians
and national testing of medical students. About
80 per cent of all U. S. medical graduates are
licensed to practice through NBME certification,
and 52 of the 55 licensing authorities in the
U. S. and Canada accept National Board certifi-
cations without requiring further examination.
Doctor Gutmann will serve on the Medicine
Test Committee for Part II, which develops the
content of National Board examinations for
medical students in medicine and neurology.
NBME test committees include more than
100 men and women chosen from among
prominent members of medical faculties through-
out the U. S. and Canada. They were described
as “the best qualified leaders in medicine” by
Edithe J. Uevit, director of the NBME, which
was established in 1915 and has principal offices
in Philadelphia.
Doctor Gutmann joined the WVU medical
faculty in 1966.
xvi
The West Virginia Medical Journal
I 7 ) ) WHEELING HOSPITAL
Medical Park, Wheeling WV 26003
Announces The Third Continuing Education Course
On
BALANCE DISORDERS
Thursday, April 28, 1983
(''Vp/'j 1 + o’ Approved for 7 Credit Hours Category I for the Physician's Recognition Award of the
AMA. Acceptable for 7 Prescribed Hours by the American Academy of Family Physicians.
QOU TSG’ "^' S course ' s designed for the family practitioner and the many various specialists
seeking better understanding and improved competence in the diagnosis and
management of the patient with any form of dizziness or diseguilibrium. The
registration fee is $30.00 and includes the course-related materials, luncheons,
refreshments and cocktails. The topics covered will include:
Topics:
Bone Marrow Examination, Clinical Application; Plasma Cell and Blood Protein
Disorders; Auditory Brainstem Evoked Potentials, ENG, Impedance Audiometry,
Application to Clinical Otology; Management of Otitis Media in Children; Surgical
Management of Vertigo; Recent Advances in Anti-Microbial Therapy; Hyperlipidemia;
Parkinsonism, Plus Syndrome; Hypoglycemia; Clinical Management of Acute
Hypersensitivity Syndrome.
Chairman:
Hong I. Seung, M.D., Clinical Assistant Professor, Otolaryngology-Head and Neck
Surgery, West Virginia University School of Medicine, Morgantown, West Virginia.
Senior Staff, Wheeling Hospital and Ohio Valley Medical Center, Wheeling, West Virginia
Speakers:
Joseph R. Bianchine, M.D., Professor and Chairman, Department of Pharmacology;
Professor of Medicine, Ohio State University, College of Medicine, Columbus, Ohio.
rk j
C C; '
Thaddeus S. Danowski, M.D., Clinical Professor of Medicine, University of Pittsburgh,
School of Medicine; Director of Medicine, Shadyside Hospital, Pittsburgh, Pennsylvania.
Heinz F. Eichenwald, M.D., Professor and Chairman, Department of Pediatrics,
University of Texas, Health and Sciences Center, Dallas, Texas.
Michael Glasscock III, M.D., Clinical Professor of Otolaryngology, Vanderbilt University,
School of Medicine, Nashville, Tennessee.
Bong H. Hyun, M.D., D. Sc., Professor of Pathology, Rutgers Medical School;
Director, Department of Pathology, Muhlenberg Hospital, Plainfield, New Jersey.
Lodging:
Overnight Accommodations: Physicians should directly contact the reservation manager
of hotel or motor inn of their choice. Suggestions: Howard Johnson's 1-800-654-2000
and Wheeling Inn (304) 233-8500. For golf reservations at Oglebay Park’s Speidel
Course, call (304) 242-3000, Extension 156. For tennis reservations, (304) 242-3770
(indoor, Wheeling Park) or (304) 242-3000, Extension 139 (outdoor, Oglebay Park).
For further information contact Dr. Elliott at Wheeling Hospital (304) 242-7870.
Registration Form
BALANCE DISORDERS
Thursday, April 28, 1983
Name Specialty
Address City State
Registration fee is $30.00. Please make checks payable to Wheeling Hospital and mail with this form to Terry
Elliott, M.D., Continuing Medical Education, Wheeling Hospital, Medical Park, Wheeling, WV 26003.
Third-Party News, Views
and Program Concerns
Health Care Competition
Policy On Horizon
The Reagan Administration continues to move
toward its long-awaited proposal to inject more
competition into the health care economy, the
American Medical Association has observed.
Speaking before a recent national health
maintenance organization I HMO I policy con-
ference in Washington. White House health
consultant David A. Winston said he had reason
to believe a competition policy would be intro-
duced “very soon.” The annual meeting was
sponsored by the Group Health Association of
America and the American Association of
Foundations for Medical Care.
Winston, an unpaid special consultant with
responsibility for coordinating the development
of an Administration strategy for health care
reform, predicted that the proposal would in-
clude a so-called “tax cap." limiting the dollar
amount of health care benefits that are non-
taxable to the employee, and mandatory cost
sharing for certain Medicare patients.
He was less optimistic about the proposal’s
chances for enactment, saying he could not pre-
dict whether such a proposal would pass. He
was convinced, however, that top-level Admini-
stration officials were committed to making the
health care system more responsive to price.
Proposal Lags
Discussing why the Administration s plans for
a so-called “pro-competition proposal had
lagged for two years. Winston said the Admini-
stration assessment was that “almost anything
would irritate almost everyone.”
For a period, he said, “we thought seriously
that the smartest political thing” was to do
nothing. More recently, data on current and
projected health care expenditures made the
Administration take notice of a pressing need
for changes, he added.
Winston said the S56.4 billion spent on Medi-
care in 1982 year would grow, by conservative
estimate, to $100 billion by 1987 if no reforms
were enacted. Six weeks ago, health care ex-
perts, briefing the President and other top
Administration officials, estimated that total
health care expenditures in the nation would
grow to $798 billion by 1990 if the current
system was allowed to stand.
Acknowledging that the Administration was
supporting an unpopular proposal. Winston said
everyone would suffer “a certain amount of
pain" and undergo constraints to accomplish the
long-term goal of helping consumers become
more prudent buyers of health care.
AMA Supports Streamlined
FDA Drug Approval
The American Medical Association has gone
on record as supporting proposed rule changes
that would streamline U. S. Food and Drug Ad-
ministration approval of new drugs. A number
of the provisions in the proposed rule are close
to draft amendments to the Food, Drug, and
Cosmetic Act that were developed by the AMA
in 1977. and also are similar to recommendations
of the Commission on the Federal Drug
Approval Process.
The AMA has long been concerned about the
so-called “drug lag.' AMA Executive Vice Presi-
dent James H. Sammons. M. IT, said in a letter
to FDA Commissioner Arthur Hull Hayes Jr.,
M. D. Because of the FDA’s time-consuming
approval procedures, important new drugs
reached the market in foreign countries well be-
fore they were available in the United States.
By eliminating unnecessary regulation require-
ments. the proposed FDA rule changes will make
drugs available for patients “in the shortest pos-
sible time consistent with safety and effective-
ness. Doctor Sammons said in the letter.
xviii The West Virginia Medical Journal
Your profession
can help protect you...
with group insurance
at substantial savings.
Sponsored by the West Virginia State Medical Association:
■ Long Term Disability Income Protection
Pays you a regular weekly benefit up to $500 per week when you are disabled.
■ $500,000 Major Medical Plan
Covers you and your family up to $500,000 per person. Choice of $100, $250, $500, or
$1,000 calendar-year deductible Employees are eligible to participate.
■ Hospital Money Plan
Pays you up to $1 00.00 per day when you or a member of your family is hospitalized
■ Low-Cost Life Insurance
Up to $250,000 for members, $50,000 for
spouse, and $10,000 for children.
Employees can apply for up to $100,000.
■ $100,000 Accidental Death & Dismemberment
Insurance
Around the clock protection — 24 hours a
day . . 365 days a year . world wide.
■ Office Overhead Disability Plan
Pays your office expense up to $5,000 per
month while you are disabled.
■ Professional Liability Policy
McDonough
Caperton
Shepherd
Association
Group
Please send me more information about the plan(s) I have
indicated
□ Long Term Disability Protection
□ $500,000 Major Medical Plan
□ Hospital Money Plan
NAME
□ Low-Cost Life Insurance
ADDRESS
□ $100,000 Accidental Death &
Dismemberment Insurance
CITY/STATE
ZIP
□ Office Overhead Disability Policy
□ Professional Liability Policy
TELEPHONE
Mail to Administrator:
McDonough Caperton Shepherd Association Group
P.O. Box 3186, Charleston, WV 25332
Telephone: 1-304-347-0708
County Societies
HARRISON
Ms. Dexanne B. Clohan. Assistant Director.
Department of Congressional Relations of the
American Medical Association in Washington.
D.C., and Charles R. Lewis of Charleston were
keynote speakers for the 1983 Health Legisla-
tion Forum held January 6 in Clarksburg hy the
Harrison County Medical Society.
Lewis is Executive Secretary of the State
Medical Association.
The forum, which was held at the Sheraton
Inn, was co-sponsored by the Auxiliary.
State Senator Gino R. Colombo, Clarksburg,
and Senator Jean Scott Chace, Weston, and State
Delegate Percy C. Ashcraft II. Clarksburg,
participated in the forum. Also present were
representatives of local hospitals, community
health and other agencies.
The forum was attended hy 80. — Caspar Z.
Barcinas. M. D.. President.
* * •
WESTERN
The Western Medical Society met on January
18 in Ripley at Jackson General Hospital.
The guest speaker was Dr. Paul D. Saville of
Charleston. Clinical Professor of Medicine at
West Virginia University School of Medicine,
who spoke on non-steroidal and anti-inflam-
matory drugs.
The Society approved the drafting of a letter
in protest of the announced closing of Spencer
State Hospital to he sent to Governor John D.
Rockefeller IV ; Dr. L. Clark Hansbarger, State
Health Director; Charles R. Lewis, Executive
Scecretary. State Medical Association, and the
West Virginia Congressional delegation. — Ali H.
Morad, M. D., Secretary.
* # #
McDowell
David H. Cleland of Charleston was the guest
speaker for the meeting of the McDowell County
Medical Society on January 12 in Welch at
Stevens Clinic Hospital.
Cleland is Medical Relations Officer for the
Disability Determination Service, West Virginia
Division of \ ocational Rehabilitation. He spoke
to the Society on the changes in disability
determination over the past 10 to 20 years, and
clarified the physician’s role and criteria used to
determine if a person is disabled. — John S.
Cook. M. D.. Secretary.
* # #
FAYETTE
Dr. Saghir Mir, Montgomery orthopedic
surgeon, was the speaker for the meeting of the
Eavette County Medical Society on January 5
at Montgomery General Hospital.
Doctor Mir spoke on “Advances in Ortho-
pedics.’’
The Society approved sending a letter to
Governor John D. Rockefeller IV asking for
support of State Medical Association-endorsed
legislation to limit awards in malpractice suits. —
Serafino S. Maduedoc, Jr., M. D., Secretary-
Treasurer.
EQUIPMENT WANTED
WANTED TO BUY— Second hand office
and exam room equipment. Also, instru-
ments appropriate for Family Practice.
Send responses to Joseph I. Golden, M. D.,
P. O. Box 1645, Beckley, WV 25801.
Summer CME Cruise/Conferences
on Legal-Medical
Issues
APPROVED FOR
24 CME CREDITS
CATEGORY 1
By the Suffolk Academy
of Medicine
The programs listed below were scheduled prior to
12/31/80 and conform to IRS tax deductibility re-
quirements under Sec. 602 of the Tax Reform Act
Public Law 94-4 45 effective 1 '1 H 7 .
•ALASKAN CONFERENCE July 2 16, 1983
Visit Victoria, Vancover, Juneau, Columbia and Mala
spina Glaciers, Seward.
•CARIBBEAN CONFERENCE July 27-Aug 6,
1983 Visit St. Thomas, Antigua, Barbados, Martin-
ique, and St, Croix ,
MEDITERRANEAN CONFERENCE Aug 20
Sept 3, 1983. Visit Maior Cities in Italy, Greece,
Egypt, Israel, Turkey, Yugoslavia.
*FLY ROUNDTRIP FREE
EXCELLENT GROUP FARES - FINEST SHIPS
The number of participants in each conference is limited.
Early registration is advised.
For color brochure
and additional
information contact
International Conferences
189 Lodge Ave.
Huntington Station, N.Y. 1 1746
Phone (516) 549-0869
XXII
The West Virginia Medical Journal
Book Review
STAND TALL! — THE INFORMED
WOMAN’S GUIDE TO PREVENTING
OSTEOPOROSIS — Morris Notelovitz, M. D..
and Marsha Ware. 208 pages. Price $12.95.
Triad Publishing Company, Inc., P. 0. Box
13096. Gainesville, Florida 32604. 1982
The overtones of the Marine Corps in the
title of this book are misleading. It is a book
written to explain what is known about
osteoporosis and its prevention and management,
primarily for a lay audience but also for health
professionals. There are descriptions of bone
anatomy and physiology, and information on the
variety of factors that can affect bone resorption
and deposition. The sites where osteoporosis
occurs, and why, are covered. There also is in-
struction on how it can be measured, and there
are chapters on how to prevent or manage the
condition together with some illustrative case
histories.
At this time it isn't feasible to use the research
methods that can accurately measure bone
density on a regular screening basis; to wait
for the first fractures to occur is much too late.
What this book has to offer is a discussion of the
risk factors and the ways that life style can be
altered to reduce the likelihood of developing
the condition. From a review of the case reports
and the way the histories taken are used to direct
management strategies it is clear that the
approach has a wide potential nationwide, in
primary care, for women from the age of 30 up.
I can therefore heartily recommend this book.
One of its strengths is its lucid writing and the
care taken not to overstate what is known or can
be done. I therefore hope it will be widely and
well used by primary care practitioners and their
patients. — R. John C. Pearson, M.B., M.P.H.
VENEREAL DISEASE SERVICES
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24-Hour Toll-Free Number
Dial 800-642-8244
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WEST VIRGINIA STATE
DEPARTMENT OF HEALTH
MEDICAL DIRECTOR OPENING
Medical Director, full or part time, Mid-
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Calhoun, Pleasants, Roane, Wirt, Ritchie &
Wood Counties. Headquarters in Parkers-
burg. Public Health Clinics a major
responsibility. Must be West Virginia
licensed M. D. Both salary and hours or
service negotiable. Call Executive Director
Ward Duel, 304/485-7374 or write Mid-
Ohio Valley Board of Health, 211 6th
Street, Parkersburg, WV 26101.
Over 80 Practice Opportunities
In rural West Virginia
CONTACT
Health Professions Recruitment Project
West Virginia Department of Health
1800 Washington Street, East
Charleston, West Virginia 25305
Phone: 348-0575
Reproductive Health Care
For Women
• Early Abortion
• Birth Control
• Pap Smears
• V.D. Screening
and Treatment
ALL SERVICES COMPLETELY CONFIDENTIAL
WHEELING MEDICAL SERVICES, INC.
600 RILEY BUILDING
WHEELING, WEST VIRGINIA 26003
TELEPHONE (304) 233-7700
March, 1983, Vol. 79, No. 3
xxiii
The Eye and Ear Clinic of Charleston, Inc.
(A Thirty-Five-Bed Accredited Hospital)
Charleston, West Virginia 25301
OPHTHALMOLOGY
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George T. Harding, Jr., M.D. Thomas D. Pittman, M.P.H.
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Member of Blue Cross of Central Ohio Accredited by the Joint Commission on
Accreditation of Hospitals
XXIV
The West Virginia Medical Journal
The West Virginia Medical Journal
Vol. 79, No. 4 April, 1983
Pain And Its Pharmacologic Manipulation
CHARLES D. PONTE, R.Ph., Pharm.D.
Assistant Professor of Clinical Pharmacy, School of
Pharmacy, and Assistant Professor of Family Practice,
School of Medicine, West Virginia University Medical
Center, Morgantown
Pain is a complex, subjective phenomenon and
difficult to evaluate. The perception of an un-
pleasant sensation and the emotional reaction to
the sensation constitute the pain experience.
The two broad categories of pain, acute and
chronic, are distinct entities requiring different
approaches in treatment. Chronic-pain manage-
ment requires regularly scheduled doses for
optimal benefit.
The strong narcotic analgesics should be em-
ployed when acute or chronic pain is most
severe and cannot be controlled effectively ivith
mild analgesics. Recent controlled trials have
shoivn that neither Brompton s Cocktail nor
heroin has an advantage over oral morphine
solution.
Newer agents may have less abuse or addic-
tion potential than conventional strong narcotic
agents. Nalbuphine and butorphanol are as
effective as morphine and may cause fewer side
effects than other narcotic analgesics.
Pain will touch the lives of all individuals at
some point. It often is regarded as an integral
part of human existence. Only during the last
50 years have the types and forms of pain and
their functions been studied adequately. Despite
this recent investigation, pain literature still may
lack scientific content. Many anecdotal reports
exist, and the subjectivity of pain makes it a
very difficult area to study.
There exists no universally accepted system
of pain measurement. Pain often is perceived
as evidence of ill health, and can cause feelings
of anxiety and fear of the unknown. This paper
will attempt to delineate briefly the nature of
the pain experience, its forms and its treatment.
There are generally two components to pain. 1
First, there is the perception of an unpleasant
sensation. The perception depends upon the
type and severity of the pain stimulus. The pain
experience from a crush injury to a finger will
undoubtedly be different than that from a pin
prick to the same finger. The second component
of pain, and equally important, is the emotional
reaction. Many cultural, psychological and
physical factors have input into the reaction.
Scandinavians and Orientals are considered very
stoic about pain whereas Mediterranean peoples
may be more expressive.
Acute versus Chronic Pain
The two broad categories of pain, acute and
chronic, are distinct entities. Their causes may
be different, requiring different approaches in
treatment. 1 " 7
Acute pain may be perceived as nature’s way
of alerting us that there is something wrong
with the body. The patient expects that the pain
will disappear rapidly. The pain also may be
rationalized as being part of the healing process.
During acute pain, certain physiological
parameters change reflexively. Cardiac rate,
blood pressure, respiration, peripheral blood
flow, palmar sweating, pupillary diameter and
muscle tension can all increase. These parameters
similarly change when anxiety is experienced.
April, 1983, Vol. 79, No. 4
69
Pain > anxiety
I
> I pain
J.
Anxiety > depression > I anxietv
t
Anxiety > hostility > loneliness > | depression
Depression insomina & eating disturbances
Chronic pain can be considered a distinct
disease entity. It cannot be rationalized as part
of the healing process, and serves no biological
purpose. It imposes great emotional, physical,
economic and social demands on the patient, his
family and society. 2 Because of its discouraging
and often unrelenting nature, chronic pain often
creates feelings of helplessness and hopelessness
in the patient. Because of their preoccupation
with pain, chronic-pain patients may become
isolated from their surroundings. The classic
example is cancer pain. Other causes of chronic
pain are found in Table 1.
Cancer patients generally fear dying in pain.
Most cancer patients do not experience severe
pain, and most can be treated effectively with
minimal sedation. 5
Lipman believes that chronic pain exists in a
continuum between an aching and agonal phase,
and that most patients can function with a dull
background ache. 8 He feels that chronic pain
comprises a psychological component consisting
of anxiety and depression in addition to the
physical component. Both components should
be treated if adequate symptom control is to be
achieved. The Figure illustrates the psychologi-
cal components of pain and their effects on pain
perception.
Acute and chronic pain, as noted, require
different treatment modalities. 9 ' 11 Table 2
TABLE 1
Examples of Chronic Pain
1.
Cancer
2.
Angina pectoris
3.
Inflammatory Disease— arthritis
4.
Headache
5.
Low back pain
6.
Phantom limb pain
7.
Burn treatment
8.
Continued bone marrow aspirations
From— Dolan M: Am Pharm
1978; (1812) : 8-13.
TABLE 2
Acute Pain
Analgesic
Mild
Aspirin (Acetaminophen)
Moderate Aspirin plus Codeine
Severe
Morphine
Chronic Pain
Aching Phase— Non-narcotic analgesics
Agony Phase— Narcotic analgesics
Adjunctive
Therapy— antianxiety agents, phenothiazines,
antidepressants, corticosteroids, antiemetics
From— Lipman AG: Am J Hosp Pharm
1976; 32:270-276.
From— Lipman AG: Am J Hosp Pharm
1975; 32:270-276.
Figure.
illustrates the prototype analgesics required to
treat different types of pain. Adjunctive therapy
has a place in the management of chronic pain
and will be discussed later.
Analgesics for Mild-to-Moderate Acute Pain
Most patients who experience acute pain can
be managed effectively with drugs such as
aspirin or aspirin-containing combinations. The
pain is self-limited and does not require more
potent narcotic analgesics. Aspirin in combina-
tion with pentazocine (Talwin) or codeine '
oxycodone appears to be more effective than
aspirin alone, and probably should be the pre-
ferred combination for moderate acute pain. 12
Aspirin remains the drug of choice for mild
acute pain. It also can be effective for mild
cancer pain. An appropriate starting dose is 650
mg orally. A higher dose of 975 mg can be used
safely. Higher doses may increase the duration
of analgesia but side effects also may be in-
creased. The average duration of effect is 4.5
hours. The drug may act peripherally on pain
receptor mechanisms, block the generation of
impulses at chemoreceptor sites for pain, or
interfere with the production of prostaglandins.
Common side effects include nausea, epigastric
pain, vomiting, occult GI bleeding and platelet
inhibition.
Acetaminophen I Tylenol ) should be used in
patients who cannot tolerate aspirin, or where
aspirin is contraindicated. The drug is
equipotent to aspirin as an analgesic and anti-
pyretic, and lacks significant gastrointestinal
side effects. Nephrotoxic and hepatotoxic reac-
tions are possible with large doses.
Propoxyphene I Darvon ) is a weak analgesic
which lacks antipyretic and anti-inflammatory
properties. Its analgesic activity has not been
demonstrated consistently in controlled trials. 13
The drug should not be considered an aspirin
substitute in cases of aspirin intolerance. This
drug has significant potential for abuse.
70
The West Virginia Medical Journal
Pentazocine, Codeine
Pentazocine (Talwin) has an analgesic effect
similar to aspirin and acetaminophen. The drug
can produce bizarre central nervous system
effects including hallucinations. The drug also
has been associated with a significant addiction
potential. The drug also may potentiate the
effects of aspirin. 14
Codeine, in equianalgesic doses, has effects
similar to aspirin but lacks significant anti-
inflammatory activity. It can cause narcotic
adverse effects including gastrointestinal distress,
vomiting, sedation, constipation and dizziness.
The non-steroidal, anti-inflammatory agents
are more expensive than the usual drugs used
to treat mild-to-moderate acute pain. They
should be reserved for use when the usual drugs
are ineffective, produce undesirable side effects
or are contraindicated. These agents may pro-
duce a lower incidence of gastrointestinal side
effects. A new agent, zomepirac sodium 100 mg
(Zomax), is approximately equal to codeine
sulfate 65 mg plus aspirin 650 mg in analgesic
efficacy.
The use of analgesic combinations may be
pharmacologically appropriate. The clinician
can take advantage of drugs which exhibit
different mechanisms of action. Aspirin with
codeine would be a common example. Aspirin-
phenacetin-caffeine combinations are without
justification and should not be used. Many
manufacturers currently are removing phenace-
tin and caffeine from their products.
Fixed-dose combinations have the disadvant-
age of reduced dosage flexibility, and their use
should be discouraged. Their cost, increased
adverse reactions and lack of efficacy should
preclude their routine use.
Analgesics for Severe Pain
When acute or chronic pain is most severe
and cannot be controlled effectively with either
single or combination mild analgesics, strong
narcotic analgesics must be used. The individual
agents vary slightly both in their quantitative
and qualitative effects, but the pharmacologic
and therapeutic properties of these drugs are
quite similar. Unlike the mild analgesics dis-
cussed, morphine and the other narcotic
analgesics exhibit increased analgesia with
higher doses.
Frequent side effects include gastrointestinal
intolerance, sedation and vertigo. Gastroin-
testinal intolerance is often mistaken for a true
allergic manifestation. A complete history of
the nature of the reaction is needed for proper
interpretation.
Respiratory depression is a serious conse-
quence of narcotic analgesic use. This effect is
dose-related and is the same for any narcotic
at equianalgesic doses. Narcotics act on the
respiratory center in the brain stem to reduce
responsiveness to rises in pCCC. Respiratory
volume is depressed, followed by a decreased
respiratory rate. However, despite severe
respiratory depression, the patient may continue
to breathe via hypoxic drive regulated by the
carotid and aortic chemoreceptors. Supple-
mental oxygen support will eliminate the hypoxic
drive and cause apnea. 1
Tolerance will develop with continued use of
these agents. A larger dose will be needed to
produce a similar effect which smaller doses
provided initially. Tolerance to adverse reac-
tions also will develop at the same rate as to the
analgesic effects. Therefore, increasing the dose
will not increase the likelihood of developing
adverse reactions.
The selection of a particular narcotic
analgesic should be based upon several pharma-
cologic factors. These include oral effectiveness,
duration of action, degree of effect on smooth
muscle, route of metabolism, and individual
variation in patient response. 1,3
Narcotic analgesics are used commonly in
suboptimal doses. 15 This may occur because of
fear on the part of prescribers of eliciting
tolerance and dependence. Patients who ex-
perience and suffer from physiological pain
respond differently to narcotics than individuals
seeking euphoric effects.
PRN vs. Regularly Scheduled Doses
Chronic pain management and prevention
require careful titration of doses of an appropri-
ate analgesic. It is easier to prevent pain than
to treat it. Higher doses of analgesics usually
are required to alleviate pain once it has
occurred.
Acute-, severe- or chronic-pain patients may
be treated with narcotic analgesics on an “as
needed" basis. Such a practice may mean more
pain for the patient. He may be hesitant to ask
for analgesics for fear that this is a sign of a
weak or bothersome patient. Continual requests
for pain medication can reinforce addictive
behavior. Nurses may be hesitant to administer
“prn" doses for fear of dependency since pain
is a subjective experience and is difficult to
assess. 1 “As needed" orders should be dis-
couraged from routine use when dealing with
April, 1983, Vol. 79, No. 4
71
chronic-pain patients. Regularly scheduled
doses may be required for severe acute pain
management for 24 to 48 hours.
Once the pain has been controlled, narcotic
requirements will usually lessen, and lower doses
can be used for maintenance therapy. The
patient should be started on a moderate dose
of a narcotic analgesic, and the dose should be
lowered every several days. The optimal dose
is between the lowest dose which was associated
with pain alleviation and the dose where the
pain returns. Such dosage titration will lower
the potential for addiction and sedation. 8
Oral vs. Parenteral Administration
The oral route of administration is the pre-
ferred and most convenient way of administering
medication. 4,14 This obviates the use of
parenteral dosing with its associated patient
discomfort and technical mode of administra-
tion.
Many narcotics are available in oral dosage
forms. These agents should never be adminis-
tered in the same dose as employed parenterally.
Except for extremely severe pain, oral narcotics
are effective unless the patient cannot absorb
oral agents.
Meperidine ( Demerol ) is an effective oral
agent when doses of 100-150 mg are adminis-
tered. Morphine also is an effective oral drug
when used in appropriate doses ( 60 mg orally =
10 mg parenterally).
Dosage Adjustments
Many chronically ill or older patients may
experience deteriorating renal or liver function
either as a consequence of their disease or from
the aging process. Such patients may require
dosage adjustments to avoid potential toxicity
from prescribed medication. Patients should
have their liver and/or renal function assessed
periodically to avoid unnecessary problems. 1
Cocktails
Brompton’s Mixture originally was used at
the Brompton Chest Hospital in England in 1952.
The original formula consisted of morphine,
cocaine, alcohol, syrup and chloroform water.
This original formula has undergone many
modifications by various individuals. The mixture
now usually contains a narcotic analgesic, a
CNS stimulant and alcohol in a flavored vehicle.
A phenothiazine frequently is added as an
antiemetic.
Recent controlled trials have shown that
neither Brompton’s nor heroin has an advantage
over oral morphine solution. Results of a study
comparing the Brompton's-type solution and a
morphine solution indicated no significant dif-
ference in pain control or in the incidence of
side effects. 16 It is apparent that none of the
ingredients in the original formula enhances the
analgesic effects of the narcotic.
The routine addition of phenothiazines to a
narcotic analgesic should be discouraged.
Narcotic-induced CNS depression, respiratory
depression and orthostatic hypotension may be
potentiated.
Adjunctive Therapy
A variety of drugs can be used with analgesics
in the management of pain. These agents have
particular benefit when used concomitantly in
the treatment of chronic pain states. 8
Phenothiazines may provide anxiolytic ac-
tivity, and are useful in managing nausea which
frequently occurs with the use of narcotic
analgesics. Their sedative properties can be
advantageous to both the patient and clinician.
Depending upon the drug chosen, the anti-
cholinergic, sedative, CNS and cardiovascular
properties may be important considerations for
a given patient.
Anticholinergic drugs should be used with
caution. Side effects including blurred vision,
dry mouth, urinary retention and constipation
may be additive to concurrent analgesic medica-
tion.
Corticosteroids may have beneficial effects in
the chronic-pain patient. These drugs may in-
crease the sense of well-being and appetite.
They also have proved beneficial in the manage-
ment of hypercalcemia which is seen in many
cancer patients.
Benzodiazepines may enhance night-time seda-
tion, thereby alleviating the insomnia associated
with chronic pain. The newer agents .with
shorter terminal half-lives, or which are not
metabolized to active compounds, may be pre-
ferred in chronic-pain patients.
Tricyclic antidepressants may be beneficial in
alleviating the reactive depression seen in cancer
patients. Careful selection of an appropriate
agent, with particular attention to sedative and
anti-cholinergic properties, should be encouraged.
The Problem of Nausea and Vomiting
Nausea and vomiting frequently occur with
the use of narcotic analgesics. Narcotics stimu-
late the chemoreceptor trigger zone in the
medulla oblongata and enhance vestibular sensi-
tivity. When phenothiazine antiemetics are not
72
The West Virginia Medical Journal
helpful, an antihistamine can be added to the
regimen. This may be very useful for the
ambulatory patient when vestibular sensitivity
contributes to the nausea.
Nausea and vomiting also can be caused by
the disease process and the cancer chemo-
therapeutic regimens employed. Antiemetics
should be given prior to the initiation of chemo-
therapy or radiation therapy in an effort to lessen
the likelihood or severity of the resultant nausea
and/or vomiting.
Newer Agonist-Antagonist Analgesics
In recent years, newer agents have been
marketed which have claimed to have less abuse
or addiction potential than the conventional
strong narcotic analgesics. These drugs include
pentazocine, nalbuphine (Nubain) and butor-
phanol ( Stadol ( . These drugs potentially can
cause respiratory depression; however, the
magnitude of the respiratory depression does
not appear to be enhanced with increasing doses.
These drugs also carry the potential to elicit
opiate abstinence syndromes in patients physi-
cally dependent on narcotic analgesics. Nal-
buphine is as effective as morphine at the
appropriate doses. Its onset, peak and duration
of action are approximately the same as mor-
phine. Minimal hypotension in post-myocardial
infarction patients has been noted. The drug
also produces less nausea and vomiting than
narcotic analgesics. 1 '
Butorphanol appears to be equally as effective
as morphine, but may be more sedating. The
cardiovascular effects are uncertain and require
further study. 18,19
Conclusions
Pain is a human experience from which no
one will escape. Only recently have researchers
been able to elucidate the complex physical,
psychological and biochemical interactions
which make up the pain experience. The
etiologic factors and type of pain should be
elucidated before appropriate or adequate treat-
ment can be initiated. The current armamen-
tarium consists of many narcotic and non-
narcotic analgesics. When used properly, they
are effective and safe drugs. The potential for
addiction is minimal, especially when narcotic
analgesics are used in the treatment of chronic
pain.
Pain management requires individualized
treatment. Plans should be formulated which
employ the most rational agents for a particular
set of patient circumstances. Through further
basic research, newer agents will be developed
which will have advantages over current agents.
Cheaper, safer and more specific drugs will bring
an added dimension to the control of pain in
all of its forms.
General Prescribing Guidelines for the
management of acute and chronic pain appear
at the end of this article. These guidelines will
offer one method of treating various pain states.
The recommendation should aid the clinician in
individualizing therapy for patients. Such an
approach may alleviate both patient and pre-
server apprehension.
Editors Note: Here are the generic drugs
and trade names ( in parentheses ) to which
reference is made in this manuscript : penta-
zocine iTalivin); acetaminophen (Tylenol);
propoxyphene (Darvon); zomepirac (Zomax);
meperidine (Demerol) ; nalbuphine (Nubain);
and butorphanol (Stadol).
General Prescribing Guidelines
Acute Pain — Orally Administered Medications
Situation 1 — Mild Pain
Aspirin/ Acetaminophen 650
mg every 4-6 hours.
Do not exceed 975 mg per
does ( Little enhanced
analgesia, increased toxicity).
Situation 2 — Moderate Pain
Aspirin/Acetaminophen plus
25 mg pentazocine every
4-6 hours
65 mg codeine every
4-6 hours
10 mg oxycodone every
4-6 hours
"Oxycodone may carry enhanced addiction
potential
Situation 3 — Severe Pain
Aspirin /Acetaminophen plus
15 mg methadone
25 mg morphine
150-200 mg meperidine
120 mg codeine
* Remember
1. Patients with acute severe pain (i.e.,
postsurgery, orthopedic procedures, ob-
stetrical procedures etc. ) should receive
the medication around the clock for at
least 24 hours. This avoids peaks and
troughs in pain intensity and maintains
sustained relief of pain.
2. These guidelines are to be applied to the
cancer patient who may have pain of
varying degree.
April, 1983, Vol. 79, No. 4
73
3. Meperidine should be administered every
three hours. Schedules indicating ad-
ministration every four to six hours are
not appropriate.
4. Each patient requires careful dosage and
dosage interval titration.
5. Exercise caution with methadone to avoid
cumulative CNS depression, especially in
the elderly and debilitated.
6. With continued therapy and tolerance de-
velopment, dosage may need to be in-
creased. Use caution but do not hesitate.
7. Aspirin should be substituted for acetamin-
ophen in patients who have inflammation
as part of their pain experience.
Chronic Pain
1. Non-tolerant patient: Use usual doses to
start; excruciating pain or inadequate
control may require a larger starting dose.
2. Attempt to reassess patient response
periodically; proper dosage titration may
eliminate the need to change medication.
3. Choose a dose that provides at least four
hours of relief. No narcotic analgesic has
a duration of action much longer than
morphine. Remember, meperidine has the
shortest duration of action.
4. Avoid the use of “prn — as needed”
dosing schedules. If “prn” is selected,
encourage the patient to ask for medica-
tion when the pain begins to bother him
or her, not when the pain is most dis-
tressing.
5. Be aware of the oral-parenteral potency
ratios when contemplating oral doses of
the narcotic analgesics. Oral dosing is the
preferred route of administration when
possible.
6. Oral administration results in a slower
onset, lower peak effect and more pro-
longed duration of action, desirable in the
treatment of chronic pain.
7. Inject parenteral analgesics through exist-
ing intravenous lines when possible. Slow
infusion (several minutes) is needed when
the intramuscular doses are used. Avoid
injecting the analgesics in the infusion
containers.
8. Select alternative narcotic analgesics when
the patient experiences adverse reactions.
9. Meperidine is less constipating and
spasmogenic than morphine. Avoid con-
comitant administration of meperidine
with mono-amine oxidase inhibitors. Re-
peated large doses may cause CNS excita-
tion ( convulsion I .
Recommendations adapted from:
Moertel 1980
Beaver 1980
(see References)
References
1. Gotz V: Control of cancer-related pain and
emesis. Monograph - Squibb C ontinuing Pharmacy Edu-
cation 1980 (Third Quarter); 1(2): 1-7.
2. Dolan M : Pain-reducing the lowest common human
denominator. Am Pharm 1978; (1812):8-13.
3. Catalano RB: The medical approach to manage-
ment of pain caused by cancer. Semin Oncol 1975; 2(4):
370-390.
4. Moertel CG: Treatment of cancer pain with orally
administered medications. JAMA 1980; 244(21):2448-
2450.
5. Houde RW : The rational use of narcotic analgesics
for controlling cancer pain. Drug Ther July, 1980, pp
41-47.
6. Beaver WT: Management of cancer pain with
parenteral medication. JAMA 1980; 244:2653-2656.
7. Davis JL et al. : Peripheral diabetic neuropathy
treated with amitriptyline and fluphenazine. JAMA 1977;
238:2291-2292.
8. Lipman AG: Drug therapy in terminally ill pa-
tients. Am J Hosp Pharm 1975; 32:270-276.
9. Shimm DS et al.: Medical management of chronic
cancer pain. JAMA 1979; 241:2408-2412.
10. Beaver WT et al.: Selecting the right analgesic
for your patient. Patient Care, Feb, 1972, pp 22-45.
11. O’Neal JT: Managing chronic pain. Am Fam
Physician 1974; 10(6):75-84.
12. Moertel CG et al.: Comparative evaluation of
marketed analgesic drugs. New Engl J Med 1972; 286:
813-815.
13. Miller RR et al.: Propoxyphene hydrochloride—
a critical review. JAMA 1970; 213(6):996-1006.
14. Moertel CG et al.: Relief of pain by oral medi-
cations— a controlled evaluation of analgesic combinations.
JAMA 1974; 229:55-59.
15. Marks RM, Sachar EJ: Undertreatment of medi-
cal inpatients with narcotic analgesics. Ann Intern Med
1973; 78:173-181.
16. Wescoe G et al.: The Brompton Cocktail no more
effective than oral narcotic analgesics in chronic pain.
Hosp Formulary, April, 1980, pp 266-268.
17. Miller RR: Evaluation of nalbuphine HC1. Am
J Hosp Pharm 1980; 37:942-949.
18. Ameer B, Salter FJ: Drug therapy reviews:
Evaluation of butorphanol tartrate. Am J Hosp Pharm
1979; 36:1683-1691.
19. Vandam LD: Butorphanol. New Engl J Med
1980; 302(7): 38 1-384.
74
The West Virginia Medical Journal
Emergency Thyroidectomy
ROMEO Y. LIM, M. D.
Clinical Associate Professor, Department of Otolaryn-
gology, West Virginia University Medical Center,
Charleston Division
Emergency thyroidectomy for severe spon-
taneous hemorrhage of a goiter has been re-
ported in various publications. The purpose of
this paper is to present a case of an enormous
goiter with tracheomalacia necessitating an
emergency thyroidectomy in order to establish
an adequate airway. The highlights of the pro-
cedure, histological diagnosis and results are
presented.
"Progressive thyroid enlargement can lead to
-*■ obstruction of the airway and swallowing
passages. 1 This is a case report of a patient who
developed tracheal obstruction due to a long-
standing goiter necessitating an emergency
thyroidectomy and tracheoplastly as a life-saving
measure.
Case Report
A 79-year-old white female patient had an
enlarging goiter for many years. In recent
months, she had progressive shortness of breath
and difficulty swallowing. Pertinent findings
revealed a well-developed, fairly well-nourished
patient with marked acute respiratory distress.
A markedly enlarged thyroid almost filled the
entire neck and measured approximately 11 x
10 x 6 cm., compressing the trachea and pushing
it toward the left (Figure 1 ). Severe inspiratory
and expiratory stridor could be heard. Indirect
laryngoscopy was attempted without success.
Included in the laboratory and x-ray findings
was a plain x-ray of the neck which showed
marked deviation of the cervical trachea to the
left with compression at approximately the
second and third tracheal rings (Figure 2).
There was calcification within the mass lesion.
Barium swallow revealed marked deviation of
the cervical esophagus to the left (Figure 3).
Electrocardiogram showed atrial fibrillation. The
hemoglobin on admission was 14.1 gms.;
hematocrit. 39.2 per cent. After completion of
the above studies, the patient was taken to the
operating room.
After induction with sodium pentothal and,
with the use of fluothane (Halothanel, the
patient was intubated with a #6.5 endotracheal
tube. The neck was then placed in hyperextended
position, prepped with Betadine and draped in
For Tracheal Obstruction
the usual manner. A transverse collar skin in-
cision was made. A superior skin flap was
elevated, subplatysmally. The deep cervical
fascia was incised at the midline. The left strap
muscles were retracted laterally to expose the
less involved side. The left middle thyroid veins
Figure 1. Enormous goiter with tracheal obstruc-
tion after intubation at operating table.
2. Figure 2. Preoperative x-ray of the neck, A-P
view, with marked deviation and compression of
the trachea to the left.
April. 1983, Vol. 79, No. 4
75
were identified, clamped, cut and ligated. The
left recurrent nerve was identified and preserved.
The left lobe was then completely mobilized after
transection of its suspensory ligament.
The dissection was then shifted to the right
side of the neck. The midportion of the right
strap muscles was transected. The right middle
thyroid veins were found to be markedly enlarged
and engorged. These were clamped, cut and
ligated. Using sharp and blunt dissection, the
immense mass was freed from its soft-tissue at-
tachment. The right inferior thyroid artery was
finally exposed; this was clamped, cut and ligated
with 2-0 silk. The right recurrent nerve was
identified and preserved. The entire mass was
then removed from its tracheal attachment and
from its suspensory ligament. The preceding
technique was based on Lore’s method of
thyroidectomy. 2
Sternothyroid Muscle Patch
On removal of the entire specimen, it was
noted that the right anterior lateral wall of the
first to the third tracheal rings had been softened
and compressed. A sternothyroid muscle patch
was used to cover the denuded tracheal rings. 3
A tracheostomy was then performed by removing
an anterior segment of the fourth tracheal ring.
Figure 3. Preoperative barium swallow showing
marked deviation of the esophagus to the left.
A #6 tracheostomy tube f Shiley ) was inserted
into the tracheostomy opening, and the anes-
thetic agent was continued through this tube.
The wound was irrigated with hydrogen peroxide
solution and saline solution. Topical thrombin
solution was instilled into the wound cavity. A
Hemovac drain was inserted and brought out
inferiorly through the skin. The right strap
muscles were approximated. The skin incision
was closed with skin clips in one layer, and a
vertical skin incision was made at the midportion
of the skin flap for the tracheostomy. A spray
( Aeroplast I dressing was applied. The approxi-
mate blood loss was 600 cc.; consequently, a unit
of packed cells was transfused. The patient
tolerated the procedure well and left the operat-
ing table in satisfactory condition. Digoxin
I Lanoxin ) was administered by the internist for
the atrial fibrillation.
The pathology report disclosed a 450-gram
multinodular thyroid gland with acute infarction
and an extensive hematoma measuring 8.5 x 8.5
x 7 cm. ( Figure 4 ). The infareted large thyroid
nodule showed gross outlines of thyroid follicles
with a thickened outer capsule. There was no
carcinoma in this nodule. The noninfarcted
adjacent thyroid tissue showed multiple smaller
nodules, which were follicular carcinoma. Around
the tumor nodules there was evidence of capsular
and small-vessel invasion.
Figure 4. Goiter weighing 450 grams with asso
ciated follicular carcinoma.
76
The West Virginia Medical Journal
Figure 5. Postoperative A-P x-ray of the neck
with tracheostomy tube in place and an improved
tracheal patency.
Hospital Course
The postoperative recovery of the patient was
uneventful. She was fully alert and was swallow-
ing well the day after the operation. She was
placed on levothyroxine 0.2 mg. (Synthroid)
daily, and was on digoxin 0.125 mg. (Lanoxin)
daily. The calcium level dropped to 7.2 mg/DL
on the seventh postoperative day; however, on
discharge 12 days later, the calcium level was
8.6 mg/DL. A tracheal plug was inserted on
the tenth postoperative day: this was tolerated
by the patient. After decannulation she was dis-
charged on the twelfth postoperative day. Post-
operative barium swallow showed the restoration
of the cervical esophagus and trachea to their
normal positions. The tracheal lumen was
adequately restored (Figure 5).
Discussion
Gradual enlargements of a goiter can lead to
obstruction of the trachea or esophagus. In most
cases of respiratory obstruction, symptoms are
long-standing, and the degree of obstruction
progresses very slowly so that patients can and
do delay seeking medical help for a long period
of time. Emergency thyroidectomy has been
performed on spontaneous hemorrhage of a
retrosternal goiter. 4 Sudden hemorrhage of a
goiter, caused by injury, has been reported fol-
lowing attempts at strangulation during a family
quarrel. 4
Summary
A case of follicular carcinoma in an enormous
goiter with severe tracheal and esophageal com-
pression is presented. An emergency thy-
roidectomy with primary repair of the tracheo-
malacia using a muscle patch is described.
Editor's Note: Here are the generic drugs
and trade names {in parentheses ) to which
reference is made in this manuscript: digoxin
[Lanoxin ) , levothyroxine ( Synthroid ) and fluo-
thane ( Halothane)
References
1. Calcaterra TC, Maceri DR: Aerodigestive dys-
function secondary to thvroid tumors. Laryngoscope
1981; 91:701-707.
2. Lore JM: Atlas of Head and Neck Surgery, ed 2,
Philadelphia, WB Saunders Co, 1973, p 618.
3. Montgomery WW: Surgery of the Upper Respira-
tory System, vol 2, Philadelphia, Lea and Febiger, 1973,
p 421.
4. Wade JSH: Respiratory obstruction in thyroid
surgery. Ann R Coll Surg Engl 1980; 62:17-24.
April, 1983, Vol. 79, No. 4
77
From the Wes! Virginia University
Medical Center
Edited By
Irma II. Ullrich, M. D.
Associate Professor of Medicine
The Noninvasive Diagnosis Of Coronary Artery Disease
Discussant:
ANTHONY P. MORISE, M. D.
Assistant Professor of Medicine , Department of
Medicine ( Section of Cardiology )
When coronary angiography is not absolutely
indicated, a noninvasive approach to the
diagnosis of coronary artery disease is often
desirable. However, because of the inherent
imperfections of noninvasive testing, the results
will always produce a relative uncertainty con-
cerning the diagnosis, especially in patients with
atypical symptoms.
This paper ivill discuss a format for approach-
ing patients with suspected coronary artery
disease by using noninvasive testing modalities.
The discussion will emphasize the application of
Bayesian analysis to both the interpretation of
test results and the selection of the test or tests
that will generate the most information in a cost-
effective manner. Also included with this dis-
cussion will be comments on the criticisms and
limitations as well as the future applications of
the Bayesian approach.
A ll clinicians who are involved in evaluating
patients suspected of having coronary artery
disease (CAD) employ their skills of history-
taking and physical examination as the initial
step. Based upon these skills, we have all seen
patients whom we thought had either a high
or low probability of having CAD, e.g., a patient
with typical angina pectoris with several strong
risk factors. These clinical hunches would many
times he put to the test by comparing them to
the accepted “gold standard,” in this case
coronary angiography, and confirmation of our
hunches would undoubtedly secure our faith in
our clinical diagnostic abilities.
There often are patients, however, who defy
categorization on clinical grounds and engender
a relative uncertainty concerning their diag-
nosis, e.g., those with atypical symptoms. Diag-
nostic studies are not usually gratifying in these
patients, and one’s faith in certain clinical
markers often is shaken considerably. Over the
past 10-15 years, considerable effort has been
put forth to explain the reason for these diag-
nostic pitfalls and to provide a practical non-
invasive method for avoiding them. Jt is, there-
fore, the intent of this discussion to elaborate
upon these two points in respect to the non-
invasive approach to the diagnosis of CAD.
Noninvasive is an unfortunate adjective
because several of the noninvasive tests are not
strictly without penetration of the skin. Never-
theless, the term is uniformly understood by all
to imply a test that is noncatheter or nonsurgi-
cal by nature, thereby carrying less risk, in-
convenience and cost.
Coronary angiography, which is the current
invasive standard for the comparison and evalu-
ation of these noninvasive studies, is a useful
clinical tool, but is by no means perfect, as has
been pointed out by Roberts et aid It is only
the angiographic delineation of coronary luminal
anatomy with often little to say about the effect
of that anatomy on the perfusion to the
myocardium downstream. In considering the
fact that most, but not all, of the noninvasive
studies investigate a physiologic aspect of the
78
The West Virginia Medical Journal
coronary system, it is not a surprising fact that
noninvasive studies will be less than perfect in
predicting the coronary, i.e., luminal, anatomy.
It is the classic case of comparing apples and
oranges, which are obviously quite different, but
both classified as fruit. Luminal anatomy and
ischemia are both expressions of coronary
atherosclerosis, but they are entirely different
categories of expression.
Add to this the fact that the hallmark for the
diagnosis of CAD is usually a qualitative as-
sessment, and the problems of comparison are
magnified further. The percentage of reduction
in the cross-sectional area of the coronary artery
that leads to a measurable physiologic change
is reasonably well defined, but the ability to
measure visually that percentage of reduction
is far from perfect. Granted, an apparent lesion
of greater than 70 per cent, more often than not.
will be physiologically significant, but what
about the lesions that “look like” 40-60 per cent?
Also, positive noninvasive study results may be
indicating other types of heart disease that are
not seen by the angiogram. Clearly, the “gold
standard needs improvement.
The list of noninvasive testing currently or
soon to be available is noted in the Table. All,
with the exception of fluoroscopy, examine the
effects of ischemia on some aspect of coronary
or ventricular physiology. These aspects also
are noted in the Table. Indeed, it is not my
intent to discuss the relative advantages of each
modality, but rather to provide a format for
interpreting the results of these tests and as-
sessing their utility in the light of their well-
documented imperfections.
Predictive Accuracy
Before discussing the format for analysis, I
would like to present some background infor-
mation. First, the accuracy of diagnostic tests
is usually indicated by the terms, sensitivity and
specificity. 1 2 These terms define the ability to
detect patients with and without disease,
respectively. These quantities say nothing as to
the probability of disease in an individual. That
particular quantity known as predictive accuracy
I PA ) or value, therefore, comments on the test
result rather than the test itself. It is a quanti-
tative expression of the likelihood that a given
test result indicates the presence of disease. In
general, it is a much more clinically useful value
than sensitivity or specificity.
These three values are all dependent upon
how a positive or negative test result is defined
and. as expected, the measured values will be
different for each test result. Herein lies the
fallacy of the conventional, but oversimplified,
classification of test results as either positive
or negative. Rifkin and Hood demonstrated
that for exercise stress testing there is a con-
tinuum of risk depending upon the absolute
amount of ST segment depression. 3 4 Virtually
all of the nine basic tests available have either
a wide range of tests results (as for exercise
ECG ) or 3-4 discrete test results ( as for exercise
radionuclide angiography). Therefore, these
multiple possible test results, rather than pro-
viding a definitive answer as to the presence
or absence of CAD, provide a probability state-
ment concerning the likelihood of disease.
Effect of Disease Prevalence
Second, a number of studies have shown that
the PA of a test result is dependent upon the
chance of the patient having CAD before the
test is administered. 3 ' 5 6 7 8 9 10 This pretest risk also
is known as prevalence or pretest likelihood, and
is the main ingredient in the format called
“conditional probability analysis,” which will be
discussed shortly. Referring to large groups,
the prevalence represents the percentage of the
population that is affected by CAD at any given
time. This principle of dependence of PA on
TABLE
Noninvasive Testing Modalities and Aspects of Cardiac Anatomy and/or Physiology Examined
1. Exercise Electrocardiography 0
2. Exercise Thallium Scintigraphy 0
3. Exercise Radionuclide Angiography 0
4. Exercise Cardiokymography
5. Exercise Echocardiography
6. Coronary Fluoroscopy 0
7. Positron Emission Tomography
8. Nuclear Magnetic Resonance
9. CAT Scanning
10. Digital Subtraction Technique
Electrical Repolarization
Perfusion
Myocardial Function
Myocardial Function
Myocardial Function
Calcification of Arteries
Myocardial Function, Perfusion, Metabolism
Myocardial Function, Perfusion, Metabolism
Myocardial Function, Perfusion
Myocardial Function
° Most-available tests with the best data to generate PAs.
April, 1983, Vol. 79, No. 4
79
prevalence or pretest likelihood is more famil-
iarly known as Bayes’ Theorem. There has been
much discussion of this theorem in the medical
literature over the last 20 years, and its mention
is increasing exponentially. 6 " 8
The prevalence for CAD has been determined
for several clinical classifications from pooled
autopsies according to age, sex and chest-pain
symptomatology. 9 Diamond and Forrester 10 also
have developed a computer program for deter-
mining prevalence considering these variables
as well as coronary risk factors. This same group
also has shown that the prevalence of disease
for asymptomatic patients ( which is much lower
than for symptomatic patients) can be approxi-
mated from the Framingham study data pre-
sented in the Coronary Risk Handbook. 9
In addition to Bayes’ Theorem, there also is
a formula bearing that name which allows for
the calculation of PA given the prevalence or
pretest risks and the sensitivity and specificity
for each test result.' Unfortunately, all of the
tests have not been investigated sufficiently to
establish sensitivity and specificity data, but
Forrester et al. have presented the sensitivity
and specificity results for pooled studies for five
noninvasive tests with data on virtually all of
the possible normal and abnormal results for
each of these tests. 9,11
Conditional Probability Analysis
With sensitivity, specificity and prevalence in
hand, one next can begin to address the question
of interpreting test results. This process is
termed “conditional probability analysis” be-
cause the originally-believed probability is modi-
fied by the conditions of an observation, in this
case, a test result. Clinicians intuitively employ
probability analysis in making diagnostic de-
cisions, but, as noted earlier, not without notice-
able imperfection or uncertainty.
Baves’ formula allows us to take a test’s
sensitivity and specificity and the patient’s pre-
test likelihood for CAD, and calculate a post-
test likelihood or PA for disease. If we take a
spectrum of prevalence ranging from 0-100 per
cent and determine the PA for each point, we
can generate a series of PAs which will form
a curve with a parabolic configuration. 9 Using
these curves, the PA for a test result can be
determined by simply knowing the pretest risk
or prevalence. These curves, as w^ell as tabular
data, can be seen in a number of excellent review
articles on this subject. 2,9,12,13 Data for exercise
electrocardiography, thallium exercise testing,
exercise radionuclide angiography, and coronary
cinefluoroscopy, which make the determination
of PA or post-test likelihood very easy, 11 recently
have been published. In addition, there is a
computer software program available which will
determine the PA for five noninvasive tests. 10
Two Interpretations
Now assuming one takes the time to determine
the likelihood of disease before or after a test,
what then does one do with this value? Clinically
speaking, there are two w r ays of interpreting the
probability. The first deals with the likelihood
of disease in the patient based upon an achieved
test result. This is a diagnostic interpretation. 9
Concerning this interpretation of the PA,
Diamond et al. 14 have suggested from the tech-
niques of information theory that a PA of less
than 10 per cent or greater than 90 per cent
should be the diagnostic end points for non-
invasive testing. In other words, if a patient’s
PA is in those ranges, further noninvasive testing
for diagnostic purposes is not warranted except
in very special circumstances.
These diagnostic end points have not been
completely validated yet but, clearly, further
noninvasive studies will only serve either to
confirm what is already strongly supported by
the evaluation to that point, or cloud the picture
considerably by moving the PA between 10 and
90 per cent. Ideally, of course, a physician
should select a threshold above which one action
will be taken and below 1 which another action
w ill be taken, e.g., consider having CAD and treat
appropriately or doing another diagnostic test.
The second type of interpretation deals with
predicting the discriminative function of a test
yet to be performed. 12 The major difference
between the two interpretations rests upon
whether the likelihood is determined before or
after the test is performed. Although it is pos-
sible to render an interpretation of an achieved
test result by finding the PA for that result, it
also is possible to see what the PA will be if the
patient generates a proposed result. 14 For
example, given a prevalence of 50 per cent in
a particular patient, one can determine whether
a negative exercise electrocardiographic result
can, for practical purposes, exclude CAD, i.e.,
reduce the likelihood to a very small number.
While in many instances this will be helpful,
the real impact of this type of interpretation will
be felt when one is considering the more ex-
pensive noninvasive studies such as thallium
scintigraphy. 1 ’ The important principle here is
avoidance of unnecessary or insufficiently dis-
criminative testing. If coronary angiography
were a quick and inexpensive test with no risks,
there would be less justification for noninvasive
30
The West Virginia Medical Journal
studies. However, since this is not so, avoidance
of the cost and risk of angiography is a major
driving force behind noninvasive testing. But
if we have utilized a number of expensive non-
invasive studies arbitrarily, we already may have
negated one of the advantages of noninvasive
testing. Therefore, the take-home message is the
following: let us try to avoid coronary
angiography if w r e can, but not at the expense
of spending more to avoid the angiogram than
it would have cost to perform it.
Practical Examples
Currently, only four or five of the noninvasive
studies in the Table have been evaluated to the
extent that tables for PA determinations are
available. 911 It should not be our intent to use
all of the testing modalities in a patient, but to
select the one or two which will yield the most
information in a cost-effective manner. 15 I
believe the Bayesian format attempts to provide
this cost-effective selection process. Although
far from its final form, it is practical in its
present state and, from studies done thus far.
it would appear that the major use of single or
multiple noninvasive studies is for the assessment
of the group of patients with a prevalence for
CAD between 10 and 90 per cent. 12,14
Further subdivision of this large group leads
to branching logic trees that are far more con-
fusing than clarifying. Let me instead present
some practical examples to demonstrate the use-
fulness of this format:
1. A 55-year-old man with typical angina
pectoris had a prevalence of 92 per cent. An
exercise stress test will be performed and. if the
test is positive, the increase in diagnostic
accuracy will be marginal (four to 96 per cent)
and will confirm what already was evident from
the history. If the test is negative, the PA will
be 73 per cent. Therefore, CAD certainly will
not be excluded. Therefore, the exercise test will
not really be useful diagnostically, although it
may be useful for other purposes. Furthermore,
it is not likely that subsequent noninvasive test-
ing will help to exclude CAD with enough
certainty to warrant its expense. This is simply
because of the fact that in this case no non-
invasive study will lower the PA enough to say
that angiography is not needed to exclude the
diagnosis.
2. If the same man had atypical angina, his
prevalence would fall to 59 per cent, and the
negative stress test would yield a PA of 25 per
cent. What you do at this point depends on your
philosophy of practice, but what is important
to understand is that there is still a one-in-four
chance of CAD. One further noninvasive study
(Thallium) would be very discriminative. If
negative, the PA will be six per cent; if positive,
79 per cent. This would be enough discrimina-
tion to make a reasonable decision. In general,
the probability information, although not defini-
tive, will be sufficient to justify a management
decision. Of course, if absolute certainty is
desired, coronary angiography is the only re-
course.
3. Let us suppose a 45-year-old woman pre-
sents with atypical angina yielding a prevalence
of 13 per cent, and her stress test yielding one
and one half mm of horizontal ST segment
depression, raises her PA to 39 per cent. A
negative Thallium scan would lower it to 10
per cent whereas a negative radionuclide
angiogram would lower it to two per cent. If
one had obtained coronary fluoroscopy after the
stress testing and obtained a negative result.
Thallium would then lower the PA to 5 per cent.
4. One final example is a 45-year-old
asymptomatic man who desires an exercise test
before starting an exercise program. Without
considering risk factors, his prevalence is six
per cent. By using the Coronary Risk Hand-
book. 16 one could modify his pretest likelihood
up or down to, for example, 10 per cent. He
then exercises, producing two mm of ST segment
depression yielding a PA of 52 per cent. How
one handles him once again depends on one’s
philosophy of practice, but a negative radionu-
clide angiogram would lower the PA to four per
cent, and a negative Thallium study would lower
it only to 16 per cent. It should be clear to the
reader that if one waits until after the test is
performed to determine the PAs, one may find
that the effort and expense were wasted. There-
fore, one can evaluate whether a single or a
series of noninvasive studies will be useful by
looking at the extremes of possible test results.
I should note that the order of test sequencing
does not influence the final likelihood. This
would allow one to modify considerably and
individualize a diagnostic approach.
Test Limitations
Thus far, 1 have touted the merits of this
approach but, to be fair, I should mention and
comment upon the criticism it has received and
its limitations. In this respect, Feinstein has been
the most outspoken, considering the application
of Bayes’ Theorem to clinical medicine. 17 His
objections have been theoretical, for the most
part, and while it is true that not all areas of
medicine are appropriate for this type of
April, 1983, Vol. 79, No. 4
81
analysis, the real merit of any diagnostic
approach ultimately should be based upon its
success and not its theoretical limitations.
Statistical independence of test results means
that the results of different tests are based on
end points that are independent of one another.
For example, two tests should not be both
looking at the same parameter such as ventri-
cular function. Since Bayes’ Theorem requires
adherence to this principle, serial application of
tests that are not independent could invalidate
the results. However, it has been demonstrated
that the influence of this principle is not signifi-
cant as long as the number of tests sequentially
employed is small. 18 This is true for the
approach presented here. Likewise, it would
appear that the most easily available tests
(starred in the Table) are independent as the
endpoints are all different ( repolarization, per-
fusion. ventricular function, and artery calcifica-
tion ) , 19
Feinstein has stated that this decision process
does not even closely resemble the real clinical
situation because of the complexity of the usual
situation and the subjective nature of the data. 1.
Also, because of the continued vagueness of the
PA. he states that clinicians usually order the
most suitable tests to rule in or rule out disease.
He states that if there is uncertainty, one should
get more data. What he fails to realize is that
in clinical medicine the most cost-effective test
should be ordered, and not always the most suit-
able one, i.e., coronary angiography. However,
with so many noninvasive tests available, the
practicing physician is often at odds with select-
ing the most cost-effective study for the indi-
vidual patient.
Bayesian Analysis Could Help
Clearly, a procedure’s cost-effectiveness is
greatly dependent upon how often it is appropri-
ately ordered. 15 Even highly sensitive and
specific tests may not lead to cost savings if they
are ordered inappropriately for patients who will
not experience a change in management result-
ing from the test. Procedures with greater risks
and inconvenience such as coronary angiography
are more likely to be appropriately ordered than
are noninvasive studies. This inappropriate
ordering only serves to promote overutilization
of the study which, in turn, tends to reduce its
cost-effectiveness. This principle was demon-
strated in a study by Feinstein himself. 20 There-
fore. Bayesian analysis could be just the method
for improving cost-effectiveness by using the
uncertainty inherent in all of these studies to
our best advantage.
Next, Feinstein stated in f977 that he knew
of no published work that demonstrated the
successful application of Bayes’ method to clini-
cal medicine. 1 ' This was a valid criticism then,
and I would certainly agree that any new
diagnostic method needs to be compared to the
current standards to see if diagnostic accuracy,
patient care and cost-effectiveness are really
improved.
Since 1977, several papers comparing the
clinical to the calculated likelihood of disease
have been published. 9,14,21,22 Hlatky et al. 22
have published data indicating that probability
calculations considering only age. sex, chest
pain, and exercise EGG response were at least
as good as the cardiologists assessment and. in
a few instances, better. These probability
calculations were improved upon when a com-
puter program involving more variables was in-
volved. 10,22 Indeed, there is a lot to be learned
concerning these techniques, but to say that their
accuracy is unproved is no longer true. In all
fairness, I have not seen any comment by
Feinstein concerning these subsequent studies.
The ultimate test will be to assess their cost-
effectiveness in some sort of randomized, pros-
pective clinical trial.
Pooled versus Local Data
One area of difficulty that is not easy to
deal with is the universally assumed values for
sensitivity, specificity and prevalence. The
sensitivitv and specificity data quoted in the
literature 911 are derived from pooled data from
many sources and may not lie the values that
practitioners are working with in their local
institutions. If the determination of the local
sensitivity and specificity is possible, this should
be done, but where this cannot be done, the
published values should be utilized as the best
and only available figures. Also, prevalence can
vary from area to area with the published figures
representing only a pooled average. 9 Obviously,
the validation of the pooled prevalence data in
a number of geographical regions would help
to weaken this criticism.
In addition to the presence or absence of
disease, noninvasive tests are also ordered, often
simultaneously, to obtain other information, e.g.,
location and severity of disease. Thus far.
standard Bayesian analysis does not consider
these other questions, but once again. Diamond
et al. have demonstrated a computer-assisted
approach which does address this important
question. 10 Further applications to these ques-
tions should be forthcoming.
82
The West Virginia Medical Journal
The exercise test long has been maligned for
its excessively high false negative rate. 23 Mostly,
this is due to the naive consideration of only ST
segment depression in the test result. When
a multivariate approach is used, much better
accuracy is obtained. 24 Santinga et al. also have
incorporated other stress test variables into their
Bayesian analysis. 23 Validation of these refine-
ments as well as others that use a multivariate
approach certainly will be necessary in order to
maximize the diagnostic capability of each test.
Unfortunately, as long as coronary an-
giography is the "gold standard,” one limitation
will always be present. For those who prefer a
yes or no answer, noninvasive testing virtually
will never be satisfactory. If one cannot deal
with uncertainty, as some have made clear, then
this type of analysis will be only an academic
exercise with no real clinical application. On
the other hand, one also should not be misled
into thinking that this analysis is a panacea that
will make gray-area decisions black or white.
It is intended as a clinical tool or guide to
complement the other clinical skills and tools,
and assist in selecting and interpreting a test or
tests so that the patient will be presented with
the least amount of uncertainty concerning a
diagnosis.
The appearance of Bayes’ Theorem in the
literature is likely to increase as long as there
are those who are comfortable with probabilities
in place of discrete yes or no answers. As to its
true cost-effectiveness, I look forward to studies
addressing this very important question.
References
1. Arnett EN, Isner JM, Redwood DR, Kent KM,
Baker WP, Ackerstein H, Roberts WC: Coronary artery
narrowing in coronary heart disease: Comparison of
cineangiographic and necropsy findings. Ann Intern Med
1979; 91:350-356.
2. Griner PF, Mayewski RJ, Mushlin AI, Greenland
P: Selection and interpretation of diagnostic tests and
procedures. Ann Intern Med 1981; 94:559-563.
3. Rifkin RD, Hood WB : Bayesian analysis of electro-
cardiographic exercise stress testing. N Engl J Med 1977;
297:681-686.
4. Weiner DA, Ryan TJ, McCabe CH, Kennedy JW,
Schloss M, Tristani F, Chaitman BR, Fisher LD: Cor-
relations among history of angina, ST-segment response,
and prevalence of coronary-artery disease in the Coronary
Arterv Surgerv Studv (CASS). N Engl J Med 1979; 301:
230-235.
5. Detry JR, Kapita BM, Cosyns J, Sottiaux B,
Brasseur LA, Rousseau MF : Diagnostic value of history
and maximal exercise electrocardiography in men and
women suspected of coronary heart disease. Circulation
1977; 56:756-761.
6. Llewelyn DEH, Anderson J: The historical de-
velopment of the concepts of diagnosis and prognosis
and their relationship to probabilistic inference. Med Inf
1980; 5:267-280.
7. Brown GW: Bayes’ Formula— Conditional probabil-
ity and clinical medicine. Am ] Dis Child 1981; 135:
1125-1129.
8. Wagner HN: Bayes’ Theorem— An idea whose
time has come? Am J Cardiol 1982; 49:875-877.
9. Diamond GA, Forrester JS: Analysis of probability
as an aid in the clinical diagnosis of coronary-artery
disease. N Engl ] Med 1979; 300:1350-1358.
10. Diamond GA, Staniloff HM, Forrester JS, Pollack
BH, Swan HJC: Computer assisted diagnosis in the
noninvasive evaluation of patients with suspected cor-
onary artery disease. J Am Coll Cardiol 1983; 1:445-455.
11. Staniloff HM, Diamond GA, Freeman MR, Ber-
man DS, Forrester JS: Simplified application of Bayesian
Analysis to multiple cardiologic tests. Clin Cardiol 1982;
5:630-636.
12. Epstein SE : Implications of probability analysis
on the strategy used for noninvasive detection of coronary 1
artery disease. Am J Cardiol 1980; 46:491-499.
13. Hamilton GW, Trobough GB, Ritchie JL, Gould
KL, DeRouen TA, Williams DL: Myocardial imaging
with Thallium 201: An analysis of clinical usefulness
based on Bayes’ Theorem. Semin Nucl Med 1978; 8:358-
364.
14. Diamond GA, Forrester JS, Hirsch M, Staniloff
HM, Vas R, Berman DS, Swan HJC: Application of
conditional probability analysis to the clinical diagnosis
of coronary artery disease. J Clin Invest 1980; 65:1210-
1221 .
15. Goldman L, Adams JB: Cost effectiveness in
medical decision making: Cardiac nuclear medicine and
exercise electrocardiograms. Cardiovasc Rev Rep 1981;
2:45-53.
16. Coronary Risk Handbook, New York, American
Heart Association, 1973.
17. Feinstein AR: Clinical biostatistics. XXXIX. The
haze of Bayes’— The aerial palaces of decision analysis,
and the computerized ouija board. Clin Pharmacol Ther
1977; 21:482-496.
18. Fryback DG: Bayes’ Theorem and conditional
nonindependence of data in medical diagnosis. Comp
Riomed Res 1978; 11:423-434.
19. Charuzi Y, Diamond GA. Pichler M, Waxman A,
Vas R, Silverberg RA, Berman DS, Forrester JS: Analy-
sis of multiple noninvasive test procedures for the diagno-
sis of coronary artery disease. Clin Cardiol 1981; 4:67-74.
20. Goldman L. Feinstein AR. Batsford WP: Order-
ing patterns and clinical impact of cardiovascular nuclear
medicine procedures. Circulation 1980; 62:680-687.
21. Diamond GA, Forrester JS: Probability of CAD
(letter). Circulation 1982; 65:641-42.
22. Hlatky M, Botviniek E, Brundage B: Diagnostic
accuracy of cardiologists compared with probability cal-
culations using Bayes’ Rule. Am J Cardiol 1982; 49:
1927-1931.
23. Epstein SE: Limitations of electrocardiographic
exercise testing. N Engl ] Med 1979; 301:264-265.
24. Berman JL. Wynn J, Cohn PF : A multivariate
approach for interpreting treadmill exercise tests in
coronary artery disease. Circulation 1978; 58:505-512.
25. Santinga JT, Flora J, Maple R, Brymer JF, Pitt B:
The determination of the post-test likelihood for coronary
disease using Bayes’ Theorem. J Electrocardiol 1982;
15:61-68.
April. 1983. Vol. 79, No. 4
83
c/£ meAAage fcom . . .
*Jhe PzeAident
ETHICS, MEDICINE AND SOCIETY
jn all the hubbub, clamor and furor of the current
debate about “cost containment,” one other con-
cept of significance seems to be emerging and quite
possibly changing. This is the broad concept called
ethics. We are all aware of the impact of ethical
considerations in our lives, but these generally have
been somewhat esoteric, and have not received
widespread publicity or public attention. Increasing
demand for unlimited, high-quality medical care
in the face of finite resources may force us all to
re-examine our beliefs about these difficult concepts
which eventually will confront us all, physicians or
laymen alike.
Of course, physicians, since the dawn of time,
have been subjected to different creeds of ethics
developed for the benefit of the patient, from the
Oath of Hippocrates down through the American
Medical Association’s Principles of Medical Ethics.
Physicians are not unfamiliar with the problems
involved in making the choices and decisions re-
quired in the care of our patients, but these choices
and decisions now apparently are spreading to in-
volve a broader segment of society. Ethical
dilemmas such as appropriate care of an in-
competent patient, possible rationing of medical
care due to increasing demand and decreasing
resources, or the advisability of withholding treat-
ment in hopeless situations, increasingly are be-
coming more prominent and publicized. These
ethical and moral decisions have been made by
physicians from time immemorial but there seems
to be a growing trend to extend this responsibility.
The question, it seems to me, is becoming who
has the responsibility or obligation to make these
decisions? In a recent study from California, it was
estimated that approximately 20 per cent of the
resources of a group of hospitals was expended to
care for people whose prognosis was less than a
year. In the Medicare program, around .5 per cent
of the patients, those with end-stage renal disease,
consume almost 10 per cent of the funds. Is it
ethical to expend so much of society’s resources on
a limited number of people or on those with very
little chance of long-term survival? If so, why?
And, if not, who is to make that decision? Is it
ethical to deny expensive and potentially painful
care to a baby born with severe birth defects, or
is it more ethical to expend all of our energy,
resources, and technology to prolong this life? Do
we place a value in dollars and cents on an indi-
vidual life? And, if so, who determines that value?
Do ethical considerations come down in the end to
a matter of money? If society as a whole pays the
bill, who has the right to dictate to an individual
what his or her choices must be?
These are indeed difficult questions. And for me,
at least, the answers are not clear. In the practice
of Medicine, however, in this day and age, there
seems to be a requirement for answers to these
possibly unanswerable questions. How do we
approach this? Is it the duty of our elected officials
to provide answers to these questions? If so, has
the Legislature understood and accepted this
awesome responsibility? Or, is it the province of
the courts to make these determinations? Will our
already overburdened legal system be able to
respond to the split-second decisions that are some-
times required? Is it able to accept this responsi-
bility in a timely fashion?
These are but a few of the many questions that
arise when ethical considerations meet harsh
economic realities. Attempting to answer these
questions will challenge us to re-evaluate our own
beliefs and behavior as well as those of others. I
feel it is the responsibility of our profession, as on
so many other occasions, again to take the lead in
evaluating these questions and trying to resolve
them. If we do not, we can rest assured others will.
Harry Shannon, M. D., President
West Virginia State Medical Association
84
Thf. West Virginia Medical Journal
The West Virginia Tledical Journal
Editorials
The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or
in communications submitted to this Journal for publication. The author shall be held entirely responsible.
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State
Medical Association.
One can still hear around Medical Society
meetings comments to the effect, “What the
profession needs is some good public relations.
The public just doesn't know enough about
what goes on in Medicine to appreciate what
they’ve got . .
Perhaps this was once true. But in recent
years we’ve been getting publicity, lots of it. It’s
hard to pick up a newspaper these days without
finding prominently displayed some story de-
picting medical technological wizardry being
applied to some unfortunate victim
PUBLIC of d isease or accident. Medical
RELATIONS columns by physician journalists
are rampant. News services scan
scientific journals and frequently announce
scientific advances before the mailman delivers
the journals. No news magazine worthy of the
name is without its Medicine section. Television
networks have full-time medical experts appear-
ing in popular time spots discussing common
or rare afflictions and giving advice. Publishing
houses solicit manuscripts and print books on
diets, exercise programs and a host of medical
fads.
One might be led to think now that, rather
than being medically uneducated, the public
knows too much. And knowing too much, they
expect too much. “Why shouldn't my father
(husband, son, mother, wife, cousin . . .) have
an artificial heart like that dentist?” Or, more
likely, “If they can put an artificial heart in that
dentist and keep him alive, why did my father
(husband, son, mother, wife, cousin . . .) die
of a little thing like a ruptured ulcer
( ruptured spleen, ruptured aorta, pulmonary
embolus . . .)?”
The increased medical sophistication of the
public has not led to increased respect and
appreciation for doctors. PDR’s are a big seller;
patients now want to quiz the doctor on his
knowledge of drug side effects and incompati-
bilities, and, frequently enough, to negotiate on
which might be the drug of choice to treat their
condition.
Good public relations were supposed to make
life better for the doctor and patients easier to
deal with. Sadly, that has not happened.
Patients are now informed and doctors now
struggle to get informed consent. Patients are
smarter and less trusting. Patients and doctors
alike now have personal attorneys. Where a
family once had a bottle of Mercurochrome and
a tin of aspirin in its medicine cabinet as its
bow to medical preparedness, they now have a
sphygmomanometer.
There wasn't really too much that was good
back in the good old days of Medicine but a
medically unsophisticated patient was surely a
pleasure. There are certainly others about in
need of good public relations ... if we could
only tout the reporters onto them somehow,
maybe . . .
It’s not a mnemonic. It is hardly even an
attractive group of initials, suggesting at best,
perhaps not inappropriately, a dirge. But if
HCFA, a not very attractive group of letters
either standing for Health Care Financing
Administration of the Department of
DRGs Health and Human Services, has its
way, these will soon be as well known
to physicians as IRS or FTC.
Diagnosis Related Groups. Practically all of
Medicine is wrapped up into 467 of them. An
industrial engineer with a special knowledge of
industrial quality control accomplished this
remarkable task of distillation. A medical
product has been described; the production
process defined; and a cost control method
created.
The system developed is to be applied to
hospitalized patients paid for by Medicare.
Other third-party payors have shown a keen
interest in employing the same or a similar pro-
gram for their subscribers. Presently, it is to
apply only to hospital charges, not to physician
fees.
Although the payment mechanism has been
described as prospective, the actual payment is
s : ' F
r': fl
\u r
5
April. 1983, Vol. 79, No. 4
85
AH.VU.an S 33 K 5 Q 5
based on a discharge diagnosis for each covered
individual. The discharge diagnoses are what
constitute the DRGs. They are complex and
arborized along the lines of an algorithm: the
first division is surgical-nonsurgical; the next,
complications; then concomitant conditions;
age; discharge status; etc., etc., etc.
The final elaborated diagnostic form festooned
with all pertinent problems and procedural infor-
mation is matched with one of the 467 DRGs,
each of which carries with it a set dollar figure
tailored to the particular geographical area and
type of hospital.
One set price, no matter the LOS, time in
ICU, number of C-Ts, EEGs, the size of the
stack of x-rays or sheath of laboratory studies.
Hospital administrators are worried. The staff
could break them. Schemes to marry the clinical
and administrative functions of hospital care are
proliferating.
It’s a time for innovation. It is a time for
medical staff to be on their collective toes and
to enter into the process of shaping whatever
change is required.
Some form of a hospital payment system
using DRGs seems imminent. If physicians are
to ignore the clear handwriting on the wall on
this issue, DRGs could spell DOA to the
amicable medical staff-hospital relations such as
we presently enjoy.
Unusual Case In State
Rocky Mountain Spotted Fever (RMSF) is an uncom-
mon disease in West Virginia, with only eight reported
cases in 1982. 1 It is diagnosed more often in the border-
ing states of Maryland and Virginia, with 50 and 73 cases,
respectively, last year. 1 Peak incidence is in the spring
and summer months when both ticks and humans are
active in the outdoors. 2 So, we were surprised to find
a January RMSF case in central West Virginia.
A 14-year-old white male, a resident of West Milford
in Harrison County, presented to the Emergency De-
partment of United Hospital Center in Clarksburg on
January 15, 1983. He complained of an eight-day illness
which started with intermittent fever to 102°F, head-
ache, and myalgia. He had been seen in the office on
the third day of the illness, at which time he appeared
mildly ill, and had a temperature of 102°F, but otherwise
had a normal examination. He was sent home on sympto-
matic treatment for a presumed viral illness.
A throat culture was taken and was negative for Strep-
tococcus. His symptoms worsened and his evening tem-
perature spikes reached 104°F. On the sixth day of the
illness, a macular, mildly pruritic rash appeared on his
hands and feet and spread inwards. He also developed
a mild sore throat and had increased myalgia in his legs.
He denied any history of tick bite, although the family
does have two dogs. He had hunted and helped his
brother with trapping this winter, and had limited con-
tact with killed rabbit and other animals. The family
lives in an old house and has a problem with rats. He
had no known contact with contaminated water or food-
stuffs, had not traveled recently, and had never been
outside the northeastern United States. No one else in
the family was ill. The only medication was ace-
taminophen (Tylenol); he has no known drug allergies.
On admission, the temperature was 103. 8°F; pulse,
88, and respiration, 20. He appeared moderately ill.
Examination showed muscle tenderness on palpation of
the lower extremities, and two rashes: one, a fine,
petechial, hemorrhagic rash most prominent on his
lower legs, ankles, and soles; the other, an erythematous,
macular, papular rash on his extremities, face and trunk,-
which disappeared during the course of the examination.
The examination was otherwise unremarkable. ,
Admission hemogram showed a white count of 6,600
with 33 stabs, 23 polys and 44 lymphs; hemoglobin,
13.0 gm; MCV, 86.1, and platelet count, 119,000. Wes-
tergren ESM was 6 mm/hr. Urinalysis was normal.
Mono spot was negative. RPR was non-reactive. Febrile
agglutinins drawn on admission were positive for Proteus
OX2 at a titer of 1:80 and Proteus OX19 at a titer of
1:40; Proteus OXK, Typhoid H. Typhoid O, Brucella,
and Pasturella tularensis were negative. Cold agglutinins
were positive at a titer of 1:8; acute Mycoplasma and
Leptospira titers were negative. Blood cultures and re-
peat throat culture showed no growth. ASTO titers were
negative. Chemical profile showed alkaline phosphatase
elevated at 245 IU/L, LDH elevated at greater than
600 IU/L, and SGOT elevated at 168 IU/L. Chest
x-ray and EKG were normal.
The patient was treated with doxycvcline (Vibramvcin)
200 mg. po stat, then 100 mg. po b.i.d. He also received
acetaminophen for fever and hydroxazine I1CL (Atarax)
for itching. At no time did he appear more than mod-
erately ill. The petechial rash persisted but did not
worsen. The platelet count dropped to 89,000 on the
second hospital day, then rose. He had several more
transient episodes of a macular, papular rash which at
times had a sandpaper-like texture, and also had epi-
sodes of transient, pruritic, urticarial rash. He continued
to have evening temperature spikes which gradually de-
creased, and became afebrile on the fourth day of treat-
ment. He was discharged home on doxycycline 100 mg.
po daily to finish a 10-day course.
He was seen in the office one week later, at which
time he felt entirely well. Convalescent titers were ob-
tained two weeks after the acute titers had been drawn.
Convalescent Proteus OX2 was positive at a titer of 1:320,
showing a four-fold rise; Proteus 0X19 was 1:320, show-
ing an eight-fold rise. Other febrile agglutinins again
were negative, as was repeat mono spot and Mycoplasma
titers. Leptospira titers, and a hepatitis screen.
Comment
This patient had a fairly typical presentation for
RMSF, except that the illness was milder than expected
from textbook descriptions, and that a tick-borne zoonosis
is unexpected in January in West Virginia. The serology
is typical for RMSF; murine (endemic) typhus also could
give these results, but we feel the nature of the rash con-
firms the diagnosis of RMSF.
We assume the unusually warm winter has allowed
continued risk of tick exposure. Also of note for central
West Virginia physicians is the focal nature of RMSF
cases, with limited geographic areas accounting for a
high percentage of cases in a given state. 2
1. MMWR 31:52, 705 01/07/83
2. Scientific American Medicine 7: XI : 1
Allen L. Knowles III, M.D., PG II
Peter Id. Oostwouder, M.D., PG I
Family Practice Residency
United Hospital Center, Clarksburg
L. Dale Simmons, M.D.
Director, Family Practice Residency
UHC, Clarksburg
86
The West Virginia Medical Journal
GENERAL NEWS
VD, Gay Patient Diseases
Convention Subjects
Venereal diseases and diseases of the gay
patient will be discussed by physicians from
Marshall University and the University of Pitts-
burgh during the State Medical Association’s
116th Annual Meeting.
Lee P. Van Voris, M. D. George J. Pazin, M. D.
The two papers will be part of a “Symposium
on Sexually Transmitted Diseases ” constituting
the initial general scientific session on Friday
morning, August 26.
The convention will be held August 25-27 at
the Greenbrier in White Sulphur Springs.
Dr. Lee P. Van Voris, MU Associate Pro-
fessor of Medicine, will speak on “Non-Luetic.
Non-Gonococcal Venereal Diseases,” and Dr.
George J. Pazin, Associate Professor of Medi-
cine at the University of Pittsburgh, will dis-
cuss “Transmissible Diseases of the Gay
Patient,” the Program Committee announced.
Other individual topics for the Friday morning
session will be syphillis and gonococcal infec-
tions, and sexual mores in the 1980s. The ses-
sion will follow traditional opening exercises;
the keynote speaker for the latter program will
be announced later.
The Annual Meeting will open with a pre-
convention session of the Association’s Council
and the first session of the House of Delegates
on Thursday morning and afternoon; and end
with the second and final House session and
reception for new Association officers on
Saturday afternoon and evening.
Doctor Van Voris, effective in May, will leave
MU to become Chief of Infectious Diseases and
Hospital Epidemiologist at Hamot Hospital in
Erie, Pennsylvania. He will have the con-
tinuing appointment, however, as MU Clinical
Associate Professor of Medicine. He has been
on the MU faculty since 1978.
Doctor Van Voris was graduated from
Kenyon College in Gambier, Ohio; received his
M. D. degree in 1971 from State University of
New York ( SUNY ) Upstate Medical Center.
Syracuse; interned at Los Angeles County
Harbor General Hospital in Torrance, California;
and completed residencies at that hospital and
at SUNY Medical Center, Syracuse. He received
a fellowship in infectious diseases from 1976
to 1978 at the University of Rochester (New
^ ork ) .
Certified in internal medicine, Doctor Van
Voris is a Fellow of the American College of
Physicians, and a member of the Board of
Directors, West Virginia Chapter, Association
for Practitioners in Infection Control.
He is the author or co-author of four books
and/or book chapters, 10 abstracts, and 18
scientific articles.
‘Pitt’ Graduate
Doctor Pazin is a graduate of the University
of Pittsburgh School of Medicine and the Uni-
versity’s Health Center Hospitals program in
internal medicine. During an academic fellow-
ship in infectious diseases under Dr. A. 1.
Braude, he also earned a M. S. degree in micro-
biology.
Doctor Pazin served two years in the Venereal
Disease Branch of the U. S. Public Health
Service at the Centers for Disease Control in
Atlanta, Georgia, and completed his infectious
disease fellowship at the University of California,
San Diego, before returning to the University
of Pittsburgh. Board certified in internal medi-
cine and infectious diseases, he has published
in a wide range of areas from interferon and
herpes viruses to aminoglycoside pharma-
cokinetics in obesity; office bacteriology; candi-
diasis; endocarditis; gonorrhea, and “Pittsburgh
pneumonia agent.”
April, 1983, Vol. 79, No. 4
87
His main research efforts during the past five
years have involved investigations of the clinical
applications of human leukocyte interferon in
relation to: (1) reactivation of herpes simplex
virus following neurosurgery, (2) treatment of
extensive skin papillomas (warts) in a patient
with atopic eczema, and ( 3 ) treatment of genital
herpes in women.
The second general scientific session will be
held Saturday morning, August 27’ and, as
announced previously, will be a symposium on
cardiovascular diseases. The Saturday morning
topics will include new developments in the
management of cardiac arrhythmias; an update
relative to cardiovascular surgery, and the
management of congestive heart failure.
Special Groups
In addition to the general sessions, the Annual
Meeting agenda will include breakfast, luncheon
and other programs arranged by specialty
societies and sections, many of which also will
provide scientific discussions.
The specialty group meetings will be held in
large measure on Friday, with a few to be set
for Saturday morning, preceding the second
general sesion, and at noon.
At the final House session on Saturday after-
noon, Carl R. Adkins, M. D., of Oak Hill will he
installed as the Association’s 1983-84 President
to succeed Harry Shannon, M. D., of Parkers-
burg.
The Auxiliary to the State Medical Associa-
tion, with Mrs. Richard S. Kerr of Morgantown
Putting their heads together during the recent
16th Mid-Winter Clinical Conference in Charleston
are, from left, Drs. Harry Shannon of Parkersburg,
President of the State Medical Association: Jack
Leckie, Huntington; and David Z. Morgan, Morgan-
town. The annual continuing education program is
sponsored by the Association and the West Virginia
University and Marshall University Schools of
Medicine.
the current President, as usual will hold its
meeting in conjunction with that of the Associa-
tion.
Members of the 1983 Program Committee
are David Z. Morgan, M. D., Morgantown,
Chairman; Doctor Adkins; Jean P. Cavender,
M. D., Charleston: Michael J. Lewis, M. D., St.
Marys; Kenneth Scher, M. D., Huntington, and
Roland J. Weisser, Jr., M. D., Morgantown.
Additional information concerning speakers
and other convention details will be provided
in upcoming issues of The Journal.
Legislature Enacts Hospital,
Nurse, Therapist Measures
Bills establishing a hospital cost containment
authority, and easing registered nurses — regard-
less of levels of training — and physicial ther-
apists into independent practice sailed through
the recent legislative session during its final
hours.
Failing to pass were bills to extend from 1984
to 1987 temporary permit mechanisms for un-
licensed physicians, and require parental notifi-
cation prior to the performing of an abortion on
a minor.
The controversial nurses legislation will re-
quire, as of January 1, 1984, third-party re-
imbursement for non-salaried primary health
care nursing services and can cause substantial
problems for the insurance industry and others.
The West Virginia Nurses Association has
emphasized in its publication that its goal has
been recognition of the independent practice of
nursing, and to provide “the citizens of West
Virginia with the freedom to choose between
various health care providers.”
Referrals No Longer Required
The physical therapist bill will permit those
licensed individuals to treat persons other than
those referred by physicians, dentists or podia-
trists, as the law has required.
The bill, heavily lobbied by freshman Dele-
gate Joe Manchin III (D-Marion), was passed
finally by the Senate, 26-4, just two minutes
before the end of the regular session at midnight
on Saturday, March 12.
The final Senate vote, held up for several days,
followed Manchin’s eventual support of a largely
Senate version of the hospital cost containment
bill, passed in the Senate 21-13 and in the House
63-34 after adoption of a conference committee
report.
As this copy was written on The Journal dead-
line for the April issue, more detail on the hos-
88
The West Virginia Medical Journal
pital and other legislation will be developed
later. The Legislature provided for a three-
member rate-review and rate-setting authority to
be established within the West Virginia Depart-
ment of Health structure (see story on page 91).
Other bills enacted by the Legislature, if
approved by the Governor, will:
- — Set up a procedure for patients, upon
written request, to obtain from health care pro-
viders copies or summaries of their medical
records — with safeguard covering doctors’ notes,
psychiatric situations and others (legislation
prepared and strongly supported by the State
Medical Association).
— Require that at least 40 per cent of hospital
boards of directors be representatives of small
business, organized labor, the elderly and per-
sons with income less than the national median.
— Permit certain authorized personnel to pro-
vide corneas to the state medical eye bank
pursuant to an autopsy (supported by the State
Medical Association).
— Eliminate chest x-rays for school personnel
and children unless medically indicated.
— Provide for licensure by the West Virginia
Department of Health of birthing centers; and
authorize use of certain state funds for payment
of birthing center services.
— List specific birth defects to be reported to
the West Virginia Department of Health in
further implementation of a 1982 act supported
by the State Medical Association.
— Revise and tighten educational and other
requirements for Type B physician assistants.
— Provide that investigators appointed by the
West Virginia Board of Pharmacy need not be
registered pharmacists.
— Update the list of controlled substances in
line with West Virginia Board of Pharmacy
recommendations.
— Re-establish a 10-member Workers’ Compen-
sation Fund Advisory Board, with three mem-
bers representing providers of medical services
to employees for which such providers are
compensated by the fund (supported by the
Sate Medical Association ) .
— Permit the State Health Director to make
emergency payments for certain health care
services.
— Rename the Department of Welfare the
Department of Human Services.
— Rename the Workmen's Compensation
Fund the Workers’ Compensation Fund.
Continuing Education
Activities
Here are the continuing medical education
activities listed primarily by the West Virginia
University School of Medicine for part of
1983, as compiled by Dr. Robert L. Smith,
Assistant Dean for Continuing Education, and
J. Zeb Wright, Ph. D., Coordinator, Con-
tinuing Education, Department of Community
Medicine, Charleston Division. The schedule is
presented as a convenience for physicians in plan-
ning their continuing education program. (Other
national, state and district medical meetings are
listed in the Medical Meetings Department of
The Journal.)
The program is tentative and subject to
change. It should be noted that weekly confer-
ences also are held on the Morgantown, Charles-
ton and Wheeling campuses. Further information
about these may be obtained from: Division of
Continuing Education, WVU Medical Center,
3110 MacCorkle Avenue, S. E., Charleston
25304: Office of Continuing Medical Education,
WVU Medical Center, Morgantown 26506; or
Office of Continuing Medical Education, Wheel-
ing Division, WVU School of Medicine, Ohio
\ alley Medical Center. 2000 Eoff Street, Wheel-
ing 26003.
April 12, Summersville, Child Abuse & Neglect,
Part I (Sponsor. WVU Charleston Division)
April 15, Charleston, Aspiration Biopsy Cytology
April 15-16. Morgantown. Cancer Teaching Days
April 19, Summersville, Child Abuse & Neglect
Part II I Sponsor, WVU Charleston Division )
April 21-22. Morgantown, Workshop for Infec-
tion Control Practitioners
April 28, Wheeling, Balance Disorders
April 29, Charleston, Research Day
April 29-30, Morgantown, Orthopedic Reunion
Days
May 7, Charleston, Outpatient Infectious Dis-
eases
May 20-21, Morgantown, Health Officers Con-
ference
June 3-4, Morgantown. Anesthesia Update ’83
June 4, Charleston, 10th Annual Wildwater
Conference — Medical & Surgical Update
June 11, Morgantown, Interventional Radiology
(continued on next page)
April, 1983, Vol. 79, No. 4
89
Regularly Scheduled Continuing
Education Outreach Programs from
WVU Medical Center/
Charleston Division
Buckhannon, St. Joseph's Hospital, first-floor
cafeteria, 3rd Thursday, 7-9 P. M. — April
21, “Prenatal Disorders and Congenital
Anomalies, R. Stephen S. Amato. M. D.
May 19, “Evaluation of Infertility and Fre-
quent Spontaneous Abortions,” Bruce L.
Berry, M. D.
June 16, “Sudden Infant Death Syndrome,”
David Myerberg, M. D.
Cabin Creek, Cabin Creek Medical Center,
Dawes, 2nd Wednesday. 8-10 A. M. — April
13, “Overall Outpatient Management of Renal
Dysfunctions, Mary Lou Lewis, M. D.
May 11, “Hypertension Update,” Steven
Grubb, M. D.
Cassaway, Braxton Co. Memorial Hospital, 1st
Wednesday, 7-9 P. M. — April 6, “Clinical
Intervention in Drug & Alcohol Abuse,”
Thomas Haymond, M. D.
Madison, 2nd floor. Lick Creek Social Services
Bldg., 2nd Tuesday, 7-9 P. M. — April 12.
“Allergy Update,” Joseph Skaggs, M. D.
May 10, “Common Dermatological Problems,”
Stephen K. Milroy, M. D.
June 14, “Recently Recognized Sexually -
Transmitted Diseases,” Thomas W. Mou.
M. D.
July 12, “Approach to the Peripheral Vascular
Patient,” Ali F. AbuRahma, M. D.
Oak Hill, Oak Hill High School ( Oyler Exit, N
19) 4th Tuesday, 7-9 P. M. — April 26,
“Adolescent Sexuality: Recognizing & Treat-
ing Pathological Behavior,” T. 0. Dickey,
M. D., and Art Kelley, M. D.
IV elch, Stevens Clinic Hospital, 3rd Wednesday,
12 Noon-2 P. M. - — April 20, “Emotional
Trauma of Cancer,” Sr. Frances Kirtley, R.N.,
and Sue Warren, M. D.
Wlutesville, Raleigh-Boone Medical Center, 4th
Wednesday, 11 A. M.-l P. M. — April 27,
“Obesity: Emotional Factors in Compliance,”
John Linton, Ph.D.
IV illiamson, Appalachian Power Auditorium, 1st
Thursday, 6:30-8:30 P. M. — April 7, “Lower
Back Injury,' Robert Ghiz, M. D. (a special
program in cooperation with Workers’ Com-
pensation Fund of West Virginia)
Senate Confirms Physicians
For State Agency Roles
Executive appointments confirmed by the
State Senate during the recent legislative session
included the following:
Vest Virginia Board of Medicine: S. Eileen
Catterson. M. D., Rhodell in Raleigh County
Ifor a term to end September 30, 1985);
Thomas Harward, Belington physician’s assistant
( September 30, 1987 ) ; Frank J. Holroyd, M. D..
Princeton (September 30, 1987); Dr. Leonard
Simmons, Fairmont podiatrist (September 30.
1987): Joseph T. Skaggs, M. D., Charleston
(September 30. 1983 ), and Mrs. Frances Groves,
Martinsburg, lay member (September 30, 1987).
West Virginia Racing Commission: Robert
S. Straueh, M. D., Martinsburg (March 21.
1986).
Nursing Home Administrator’s Licensing
Board: Earl Fisher, M. D., Gassaway (June 30.
1986).
Review A Book
The following books have been received by the
Headquarters Office of the State Medical Associa-
tion. Medical readers interested in reviewing any
of these volumes should address their requests to
Editor. The IVest Virginia Medical Journal. Post
Office Box 1031. Charleston 25324. We shall be
happy to send the books to you. and you may
keep them for your personal libraries after sub-
mitting to The Journal a review for publication.
Basic and Clinical Pharmacology , by Bertram
G. Katzung, M. D., Ph.D. 815 pages. Price
$23.50. Lange Medical Publications, I,os Altos,
California 94022. 1982.
Nine Months' Reading : A Medical Guide for
Pregnant JV omen, 3rd Edition, by Robert E.
Hall. M. D. 178 pages. Price $13.95. Double-
day & Company, Inc., 245 Park Avenue, New
Y ork. New York 10167. 1983.
Living With Herpes, by Deborah P. Langston.
M. D. 198 pages. Price $7.95. Doubleday &
Company, Inc., 245 Park Avenue, New York.
New York 10167. 1983.
Current Medical Diagnosis and Treatment,
1933. edited by Marcus A. Krupp, M. D.; and
Milton J. Chatton, M. D. 1130 pages. Price $24.
Lange Medical Publications, Los Altos, Cali-
fornia 94022. 1983.
90
The West Virginia Medical Journal
Act Freezes Hospital Rates,
Sets Up Review Board
A 1983 legislative act entitled the West Vir-
ginia Health Care Cost Review Authority has
frozen all rates for hospital services in effect as
of February 1, 1983. and has put a cap on hos-
pitals gross patient revenues that permits no
more than a 12-per cent annual increase.
This same voluminous enactment, effective
from its March 12 passage date, sets up as an
autonomous entity in the West Virginia Depart-
ment of Health a three-member West Virginia
Health Care Cost Review Authority to review
and set hospital rates.
For physicians, key language in a section
setting forth the jurisdiction of the review board
will be of prime interest. Promulgation of ad-
ministrative rules and regulations to carry out
provisions of the act will be necessary to clarify
the eventual effect of the legislation.
The board, or review authority, will — as of
July 1, 1984 — begin taking jurisdiction as to
rates for health services care as they extend to
all acute care hospitals in the state except those
owned and operated by the federal government.
Other Rates Covered
The act says that board jurisdiction also will
extend to other rates as follow's:
“Those costs or charges associated with indi-
vidual health care providers or health care pro-
vider groups providing inpatient or outpatient
services under a contractual agreement with
hospitals (excluding simple admitting privi-
leges) . . .
“The jurisdiction of the board shall not
(emphasis ours) extend to the regulation of
rates of private health care providers or health
care groups providing inpatient or outpatient
services under a contractual agreement with hos-
pitals when the provision of such service is out-
side the hospital setting.’"
The act further stipulates that the board shall
not regulate rates of other private health care
providers practicing outside the hospital setting:
“provided, that such practice outside the hospital
setting is not found to be an evasion of the pur-
pose of this article (that setting up the new
review authority).”
Compromise Passed in House
The Senate-House compromise that produced
the new legislation was passed finally in the
House at 11:48 P. M. on Saturday. March 12 —
just 12 minutes before the end of the regular
60-day session I except for an extension of three
days to consider only the state’s operating
budget for 1983-84).
The voting climaxed feverish activity which
reached the panic-button stage in the final few
hours, and left in confusion those trying to keep
track of what Senate and House conferees were
putting together.
Not until Monday, March 14, was it possible
to get a reasonably clear picture of all of the
provisions of the act, which essentially took the
form of the Senate bill passed earlier in the
session. There was time for only very sketchy
floor explanations of the conference agreement
before the bill was passed first in in the Senate,
then the House.
Lost in the late shuffle of papers and negotia-
tions, apparently, was a spot for a physician as
one of seven voting members on a 12-member
advisory council to assist the three-member re-
view authority.
Voting Members
Information available during Saturday even-
ing indicated that the physician spot was assured
— but as the final version unfolded, the voting
members will include a health insurance industry
representative; an administrator of a large hos-
pital; a small-hospital administrator, and four
consumers.
The voting members, who will serve along
with five heads of state departments, will — like
the three board members — be appointed by the
governor for specific terms, subject to Senate
confirmation.
The new authority also will become the state’s
health planning and development agency as of
July 1, 1984, and take over functions and
responsibilities of the certificate of need pro-
gram for capital expenditures for health care
facilities and specified services.
As indicated in another article in this news
section, further elaboration on this and other
legislation will come in subsequent issues of The
Journal.
Residents Total Slows
The number of resident physicians in the
United States dropped percentagewise from 1976
to 1981. according to recently released figures
from the American Medical Association Physi-
cian Masterfile. In 1976, 15.4 per cent of all
physicians were residents. They made up 13.0
per cent of the physician population in 1981 —
a drop of 2.4 per cent.
April, 1983, Vol. 79, No. 4
91
Management Process Seminar
Scheduled In Bethany
An April 15-17 weekend of training on “The
Management Process for 1983 is being co-
sponsored by the Governor’s Small and Minority
Business Services of the Governor's Office
of Economic and Community Development.
Bethany College and the United States Small
Business Administration. The seminar will be
held at the Bethany Leadership Center at
Bethany, West Virginia.
Also participating are the West Virginia
Small Business Development Centers of Charles-
ton and Clarksburg, and the West Virginia U ni-
versity Business and Management Extension
Office.
This program is open to the public, those in
business or those who are interested in starting
a business.
Book Features State Native
Neurosurgeon Thomas B. Ducker, M. D., a
native of Huntington, is featured in a new book.
Not Quite a Miracle I Doubleday), The Journal
has learned. Doctor Ducker is Chief Neuro-
surgeon at the University of Maryland Hospital
in Baltimore.
The book was inspired by a Pulitzer Prize-
winning story about Doctor Ducker. In that
story, the neurosurgeon attempted to remove a
deadly blood vessel malformation from the brain
of a Baltimore woman. In the new book, Doctor
Ducker, a 1955 Huntington High School gradu-
ate, is depicted in true stories involving a num-
ber of patients.
Enjoying a coffee break during the Mid-Winter
Clinical Conference held recently in Charleston are,
from left, Drs. James E. Boggs, Ivydale (Clay
County), and J. L. Mangus and Ralph H. Nestmann,
both of Charleston. Some 250 physicians and others
attended the annual continuing medical education
event.
Doctor Mufson Presents
Paper In Norway
Dr. Maurice A. Mufson of the Marshall Llni-
versity School of Medicine and the Huntington
Veterans Administration Medical Center partici-
pated in an international scientific symposium
in March in Beitostolen. Norway. Doctor Muf-
son. Chairman of the school’s Department of
Medicine, presented a paper on “Mycoplasma
hominis — A Review of its Role as a Respiratory
Tract Pathogen of Man.“
He said the meeting provided the most up-to-
date review of M. hominis, which can cause
pneumonia and tonsillitis and may be linked to
serious lung disease in newborns.
The symposium was underwritten by the U. S.
Food and Drug Administration, the World
Health Organization, the International Organiza-
tion of Mycoplasmology and the Scandinavian
Society for Genitourinary Medicine.
Doctor Mufson is a member of the Program
Committee for the annual January Mid-Winter
Clinical Conference sponsored by the State Medi-
cal Association and the MU and West Virginia
University Schools of Medicine.
Anesthesiologists Plan
Meeting June 3-4
Speakers from Texas, Pennsylvania, Virginia
and Maryland will make up the guest faculty
for the annual meeting of the West Virginia
State Society of Anesthesiologists June 3-4.
The meeting, “Anesthesia Llpdate ’83,” will be
held in Morgantown at the Holiday Inn.
Guest faculty members will be Yadin David.
Ed.D., Texas Heart Institute, Houston, who will
speak on “Anesthetic Vaporizers — Performance
Assurance Program;” and Drs. Norig E. Ellison,
University of Pennsylvania, “New Trends in
Intraoperative Blood Transfusions; David E.
Longnecker, University of Virginia, “Anesthetic
Considerations in Hypertension;" and Robert W.
McPherson, Johns Hopkins University, “The
Effects of Anesthetic Agents on Intraoperative
Neurological Monitoring.”
Speakers from the Department of Anesthesi-
ology at West Virginia University Medical
Center will be Drs. Robert Bettinger, “Use of
Epidural Narcotics;” Gary S. Sklar. “Control of
Ad verse Psychological Reactions to Ketamine;”
and Barry L. Zimmerman, "Invasive Monitor-
ing: What Do the Numbers Mean?.”
92
Tin: West Virginia Medical Journal
Collection Service Outlines
Background, Operation
Editor s Note: The 1. C. System, Inc., of St.
Paul, Minnesota, as reported previously, has
been recommended by the State Medical As-
sociation as a collection agency for West Vir-
ginia physicians. The company has submitted
the following release providing additional infor-
mation about its background and operations.
“Members [of the West Virginia State Medical
Association] now have a uniform collection
system approved for their use. It employs the
latest techniques available, consistent with all
requirements and provisions of the increasingly
strict laws governing collection practices. The
official announcement letter to members outlined
the program, but did not go into the particular
qualifications of the company chosen to serve the
membership, I. C. System, Inc.
“I. C. System has been in the collection busi-
ness since 1938. It now serves the members of
over 1,000 state business and professional as-
sociations and societies all across the country.
The company is currently collecting at a rate of
some $5 million per month in past-due accounts.
“All collection practices, procedures and ma-
terials used by I. C. System have been scruti-
nized by the Federal Trade Commission. So
without reservation, all members can be assured
that the company is fully aware of what can and
cannot be done on behalf of its clients. And
I. C. System's hold-harmless indemnity agree-
ment assures members that they are in no danger
of legal action resulting from collection activities
carried out by the company on their behalf.
That’s particularly important in this age of con-
sumerism.
Entrusting Name
“Years ago, the most important consideration
in selecting a collection service was to determine
its ability to collect and its willingness to turn
over to the creditor all the money he had coming
to him. Today, such selection equally empha-
sizes the importance of entrusting one’s own
good name and reputation to the collection
service ... a heavy responsibility.
“Keeping pace with the increases in collec-
tions over the years has been development of
improved data processing and customer service
departments. The company has a modern, tailor-
made data processing system backed up by auto-
matic typewriters, microfilm equipment and a
complete in-house printing and mailing cap-
ability. This enables the company to keep pace
April. 1983, Vol. 79, No. 4
with its growth and to respond immediately to
customer needs and inquiries.
“The company maintains a staff of customer
relations personnel whose job it is to see that
all customer inquiries are handled on a “right
now” basis. And for those situations in which
the mail cannot carry information fast enough,
the creditor can telephone the company via their
toll-free WATS line system.
“Borrowing from the experience of users in
other states, members who install the system
should submit nine or more accounts immedi-
ately. Even if it’s necessary to go back a year
or more to come up with that many bad checks
or written-off accounts, it’s well worth the effort.
You can expect as high a percentage of collec-
tions on the very old accounts, but the initial
heavy use will get your people accustomed to
working with the service and thus less likely to
overlook future accounts as they become 60 or
90 days past due. A company representative
will be happy to spend some time with your
people to start things off on the right foot.
“Those members who did not return the
inquiry card enclosed with the original an-
nouncement letter can arrange to see a repre-
sentative at a later date by simply contacting
the office.”
State Psychiatrist To Talk
In Ohio, Maryland
Dr. Edmund C. Settle. Jr., of Charleston will
be the featured speaker in a one-day educational
program sponsored by the Wright State Uni-
versity School of Medicine on April 16 in
Columbus. Ohio. The program has been planned
for a statewide audience of primary' care physi-
cians, and will deal with the care of psychiatric
patients in primary practice.
The meeting is under the combined auspices
of the Ohio Department of Health, the Depart-
ments of Psychiatry and Family Practice of
Wright State University School of Medicine, and
the School of Nursing of Wright State.
Doctor Settle, who is in private practice and
is Clinical Associate Professor of Psychiatry at
West Virginia University, also will be serving
as moderator of a two-day symposium, “Affec-
tive Disorders Reassessed: 1983,” at Taylor
Manor Hospital in Ellicott City, Maryland, on
April 8 and 9. This program will feature
speakers with expertise in biologic aspects of
psychiatry from the United States and Canada.
93
Child Abuse CME Program
Set In Summersville
A continuing medical education program on
“Child Abuse and Neglect” will be presented
in two sessions by the WVU Medical Center/
Charleston Division on April 12 and 19 in the
Nicholas County Courthouse, Summersville.
The time for both sessions will be from 7 to 9
P. M. The featured speaker will be Kathleen
Preville, M. D., Coordinator of Pediatric Clinics
at the Charleston Area Medical Center.
The first) session will focus on the medical
aspects of child abuse and, the second, on con-
sideration of the establishment of a county
treatment plan. Co-sponsor for the program is a
consortium of local civic groups and govern-
mental agencies. All health professionals are
welcome.
The program is approved for four credit hours
in Category 1 of the Physician’s Recognition
Award of the American Medical Association, and
.4 Continuing Education Units.
For more information, contact Beth Jordan,
R. N., at 872-4649 in Summersville, or John
Aukerman at 347-1294, Division of Continuing
Education, WVU Medical Center /Charleston
Division.
MU Succinimides Study
Grant Received
A Marshall University School of Medicine
researcher has received a $201,997 grant to
study why chemical compounds used as anti-
epileptic drugs and fungicides ( and also found
in cigarette smoke) sometimes cause kidney
damage.
Dr. Gary 0. Rankin, Associate Professor of
Pharmacology, will study succinimides, a group
of compounds with similar structures. He said
scientists have known since the 1950s that some
succinimides cause kidney damage. However,
he believes very few researchers are trying to
find out why they are toxic — and why others,
such as the principal anti-epileptic drugs, are
not.
Doctor Rankin said kidney damage from suc-
cinimides isn't a big problem in the LTnited
States, but he believes it could become one. He
noted that 1,000 succinimide-based drugs for
epilepsy were introduced for testing between
1966 and 1976.
His three-year grant is funded by the National
Institutes of Health.
Medical Meetings
April 7-8 — WV Chapter, Am. Academy of Pediatrics,
Beckley.
April 11-14 — Am. College of Physicians, San
Francisco.
April 15-17 — WV Chapter, AAFP, Morgantown.
April 16-21 — Am. Academy of Pediatrics, Phila-
delphia.
April 17-21 — Am. Urological Assoc., Las Vegas.
April 17-22 — Operative Treatment of Fractures &
Nonunions (Johns Hopkins University), Hot
Springs, VA.
April 18-22 — Am. Roentgen Ray Society, Atlanta.
April 21-23 — Medical & Chirurgical Faculty of MD,
Cockeysville.
April 22-24 — Medical Staff Leadership Seminar
(Southern Medical Assoc.), Hilton Head, SC.
April 23 — WV Diabetes Assoc., Charleston.
April 24-28 — Am. Assoc, of Neurological Surgeons,
Washington, D. C.
May 2-6 — Am. Psychiatric Assoc., New York City.
May 4-7 — WV Chapter, Am. College of Surgeons,
White Sulphur Springs.
May 6-8 — Southern Medical Assoc. Regional Post-
graduate Conference, Lexington, KY.
May 8-12 — Am. College of Obstetricians & Gyne-
cologists, Atlanta.
May 13-14 — Topics in Cardiovascular Diseases (Am.
Heart Assoc.), Baltimore.
May 19-20 — National Conference, Breast Cancer
(Am. Cancer Society), Boston.
May 20-22 — Am. Counseling Assoc., Morgantown.
May 26-28 — Am. Assoc, of Genitourinary Surgeons,
White Sulphur Springs.
June 19-23 — Annual Meeting of AMA House, Chi-
cago.
Aug. 25-27— 116th Annual Meeting, W. Va. State
Medical Assn., White Sulphur Springs.
Sept. 29-Oct. 2 — Am. Society of Internal Medicine,
San Francisco.
Oct. 16-21 — Am. College of Surgeons, Atlanta.
Nov. 6-9 — Scientific Assembly, Southern Medical
Assoc., Baltimore.
94
The West Virginia Medical Journal
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WVU Medical Center
-News—
Compiled from material furnished by the Medical Center
News Service, Morgantown, W. Va.
Unemployed Told Not To Go
Without Treatment
Physicians in WVU’s Medical Group Practice
have told their patients that financial difficulties
should not stop them from seeking needed medi-
cal services.
In a letter sent to each patient, the doctors
note that special financial arrangements can be
made to cover bills for necessary treatment.
“Patients who bring to our attention their
financial difficulties resulting from unemploy-
ment can make some type of mutually agreed
on payment schedule tailored to the patient’s
current situation,” said Robert D’Alessandri,
M. D., Chief of the Section on Comprehensive
Medicine.
“We do not want our patients to hesitate to
seek needed medical care because of financial
problems beyond their control. We have sent
letters to all patients of the Medical Group
Practice explaining this policy.”
Up to 1,100 Seen Monthly
Between 1,000 and 1,100 patients are seen
each month in the Medical Group Practice,
which is the outpatient general practice unit of
the WVU Medical Center.
Conrad Pesyna, Business Manager for the
Medical Group Practice, says that since Novem-
ber his office has been monitoring the number
of patients having particular difficulty in making
payments, and the number has increased signifi-
cantly.
“All of our patients are screened at each visit
to determine their payment status. Those with
financial problems are routed to the business
office to make payment arrangements before
seeing their doctor.
“This has been our policy all along but since
so many more patients are finding themselves
in a financial bind and some are losing their
health insurance coverage, we’re making a
\iv
special effort to assure our patients that special
arrangements can be made if necessary,” Pesyna
explained.
Seven Students Elected To AO A,
National Honor Society
Seven third-year students in the WVU School
of Medicine have been elected to the national
honor medical society, Alpha Omega Alpha.
Michael Nunley and Richard Weidman, both
of Charleston; Richard Loeser, Huntington;
Patrick Allender, Valerie Lazzell and Frederick
Zeller, all of Morgantown, and Salvatore Paras-
candola. West Babylon, New York, are WVU’s
newest AOA members.
They bring the total student membership to
20, joining six from the fourth-year class who
were elected last fall, and seven elected in their
third year last spring.
The others are Stephen Powell, Scott Depot,
President; Anne C. Cutlip, Morgantown, Vice
President; Carolyn Looney, Van Sant, Virginia,
Charleston Division Vice President; Michael T.
Angotti, Clarksburg; Linda Gray, Elm Grove;
Lynn H. Harris, Baltimore; Richard J. Jackson,
Martinsburg; Gary Renaldo and Ralph A.
Sellers, Fairmont; Gregory D. Snodgrass, Gauley
Bridge; Jack Steel, Barrackville; Vincent
Traynelis, Morgantown, and Daniel W. Wilson,
St. Marys.
The WVU chapter also elected a faculty mem-
ber, Dr. John A. Belis, Associate Professor of
Urology, and an alumnus, Dr. Dominic Gaziano
of Charleston.
Better Eye Care For Workers
A pilot program to encourage effective eye
care for industrial workers has been launched
by the American Academy of Ophthalmology
under the direction of a WVU eye specialist,
Dr. George W. Weinstein, Chairman of Ophthal-
mology. The project is under way for an esti-
mated 35,000 employes of U. S. Steel Corp. and
Duquesne Light Co. in the Pittsburgh area.
Tiik Wf.st Virginia Medical Journal
A NATIONAL INDUSTRIAL BACK SYMPOSIUM
June 22-26, 1983
The GREENBRIER HOTEL
White Sulphur Springs, W.VA.
A deliberately broad-based faculty addresses the “collective
state of the ache” for Physicians and other Health Care
Providers, Decision-makers in Industry, the Legal Profession
and the Insurance Industry.
25 Hours CME (Marshall University School of Medicine)
Distinguished Faculty
John Acken JD
Gunnar Anderson. MO
Gordon Clemons
Larry Clevenger
George Cottrill. MD
Henry Goldberg. MD
Judith Greenwood. PhD
John Haight. JD
Scott Haldeman. DC. MD
Hamilton Hall. MD
includes:
Nelson Hendler. MD
Jelfery Kreider
Tom Lahman. MD
John McClaughtery. JD
Robin McKenzie. M.N.Z.M.T.A.
T. Rothrock Miller. MD
Hugh Murray. RPT
Sally Oxley. RPT
Malcolm Pope. PhD
Patricia Posey. RN
Stanley Presier. JD
Carl Roncaglione. MD
Norman Rosen. MD
Charles Sadler. MD
Herschiel Sims
Terrence Strobbe.PhO
Lloyd Sutter. JD
Lawrence Thebo
Samuel Weizel.MD
E.W. Whitetord. MD
Hugh Wylie. MD
Includes a morning on Disability Evaluation of the Low Back
Sponsored by:
Scott, Craythorne, Lowe, Mullen & Foster, Inc.
A Private Orthopedic Group
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Recovery & Rehabilitation Services, Inc.
For Information: Call: Sharon Christopher 304-525-6905
Write: N.I.B.S
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Huntington, W.Va. 25702
Third-Party News, Views
and Program Concerns
AMA Fears Loss Of Quality
If DRGs Approved
The American Medical Association has testi-
fied against the Reagan Administration’s pro-
posal to base Medicare payments to hospitals on
the patient’s diagnosis.
Appearing recently before the House Ways
and Means Subcommittee on Health, Jerald
Schenken, M. D., a pathologist from Omaha,
Nebraska, and Vice Chairman of the AMA’s
Council on Legislation, recommended that the
committee “reject the Administration's proposal
to impose an untried system across the nation.”
He called instead for more prospective pay-
ment demonstration projects and further analysis
of the demonstration projects already in place.
The AMA opposes “a radical change in the
Medicare hospital reimbursement system without
assurances that quality of care will be main-
tained,” he explained.
467 DRGs Proposed
Doctor Schenken said the proposal, which
would set a price for each of 467 diagnosis-
related groups (DRGs) and which the Adminis-
tration wants to implement nationwide October
1 "has never been tried, even on a limited
scale.”
The DRG experiment in New Jersey, which
began three years ago, differs significantly from
the Administration proposal, and in any event,
the New Jersey experiment has not been
evaluated yet, he said.
The Administration’s proposal, which was
moving toward congressional approval as part of
the Social Security package, aims to control the
spiraling costs of Medicare, which now devotes
68 per cent of its $60-billion budget to hospitals.
Proponents of the plan say that if hospitals
were paid per DRG, they would have an in-
centive to be efficient. Hospitals now are
reimbursed by Medicare on the basis of their
costs.
The DRG system divides illness into 467
categories by primary and secondary diagnoses,
the primary procedure used (if there is surgery),
the age of the patient and the patient’s dis-
charge status. DRG 167, for example, is an
appendectomy without complicated principal
diagnosis, complications, or associated illness
for a patient under 70.
Hospital Association Proposal
The American Hospital Association also has
proposed a DRG-based prospective payment
system for Medicare, although it differs from
the Administration’s proposal on several points,
particularly as to how prices for each DRG
should he determined.
Doctor Schenken said the AMA “has some
of the same concerns about the AHA proposal
as it has about the Administration’s.” He added,
however, that he saw merit in experimenting
with the proposal.
The AMA supports experimentation with
prospective payment systems that create in-
centives for hospitals to be more cost conscious,
Doctor Schenken testified. He called upon the
committee to authorize that the Administration’s
proposal “and other prospective pricing pro-
posals” be demonstrated on a limited scale in
various states before being considered for
national implementation.
Quality of Care Reduced
Doctor Schenken said that if a hospital were
underfunded by Medicare, it would respond by
shifting costs to other payers, deferring such
costs as maintenance, reducing nursing and other
essential patient care staff, and postponing or
eliminating necessary modernization and tech-
nological improvements, thus depriving patients
of the highest quality of care.
“In extreme cases, hospitals providing essen-
tial care could be forced to close,” he said.
He added that the AMA was concerned that
the Administration's proposal could foster a
two-tiered system of health care, with one level
of care for private-pay patients and one for
Medicare patients.
xvi
The West Virginia Medical Journal
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In 1980, Saint Albans
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In addition to our general
psychiatric services, we offer
specific programs for alcohol-
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children/adolescents, and
older adults.
Saint Albans, the only
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When you have a patient
who needs the specialized ser-
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call Saint Albans. Admission
can be arranged 24 hours a
day by calling 703 639-2481.
ctive Medical Staff:
Rolfe B. Finn, M.D., Medical Director
William D. Keck, M.D.
Morgan E. Scott, M.D.
Don L. Weston, M.D.
Davis G. Garrett, M.D.
D. Wilfred Abse, M.D.
Hal G. Gillespie, M.D.
Basil E. Roebuck, M.D.
O. LeRoyce Royal, M.D.
A
Saint Albans
feychiartric Hospital
P. O. Box 3608
Radford, Virginia 24143
Saint Albans Psychiatric Hospital is approved for Blue Cross,
Cham pus, Medicare, and most major insurance companies.
For a free brochure, write Robert L. Terrell, Jr., administra-
tor, P. O. Box 3608, Radford, Virginia 24143.
| 'g
riv
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AHvaa n ktiv.
Obituaries
DANIEL N. BARBER, M. D.
Dr. Daniel N. Barber of Charleston, Treasurer
of the State Medical Association from 1958 to
1965, died on February 20 in a hospital there.
He was 85.
A native of Charleston, he was the son of the
late Dr. Timothy L. Barber, who founded the
Kanawha Valley Hospital in Charleston. He was
a member of the board of directors of the hos-
pital, which now is located in a new building
in Charleston.
Doctor Barber, a general practitioner, began
practice in 1932 in Widen I Clay County),
moving back to Charleston after several years.
He was graduated from West Virginia Uni-
versity, and received his M. D. degree in 1932
from Harvard Medical School. He interned at
Hartford (Connecticut) Hospital.
A veteran of World War 1, Doctor Barber was
an honorary member of the Kanawha Medical
Society, West Virginia State Medical Associa-
tion and American Medical Association.
Surviving are the widow and two sons, James
D. Barber, Ph.D., a professor at Duke Uni-
versity, and Timothy Barber, Charleston lawyer.
« » •
MAX O. OATES, M. D.
Dr. Max 0. Oates, retired Martinsburg
surgeon, died on February 9 at his home. He
was 85.
He devoted most of his adult life to the
development and operation of City Hospital, for
which he served as Chief Executive Officer from
1951 until his retirement in 1976. He previously
had been Superintendent of the hospital (1941-
1951).
Doctor Oates was appointed Medical Director
of the hospital in 1972. Following retirement, he
continued to serve as hospital Treasurer and as
a member of the board of trustees until his death.
Other posts held with the hospital included
those as Chairman of the Department of Surgery,
and President of the medical staff.
Doctor Oates was a Past President of the
Eastern Panhandle Medical Society, and a Fellow
of the International College of Surgeons and the
International Academy of Proctology.
Born in Capon Bridge (Hampshire County),
he received both his undergraduate and M. D.
(1929) degrees from Johns Hopkins University.
He interned at Johns Hopkins Hospital, and
took his residency at Duke University Hospital.
xviii
Doctor Oates was an honorary member of the
Eastern Panhandle Medical Society, West Vir-
ginia State Medical Association and American
Medical Association.
Survivors include the widow; two sons, Max
0. Oates, Jr., of Flint, Michigan, and Dr.
Theodore K. Oates II of Rochester, New York;
and a daughter, Mary Elizabeth Oates of
Williamsport, Pennsylvania.
# * *
LEO H. T. BERNSTEIN, M. D.
Dr. Leo H. T. Bernstein, Martinsburg internist,
died on February 13 at his home there. He was
64.
Doctor Bernstein was a member of the State
Medical Association's Council from 1978 to
1982.
The first internist in Martinsburg and a mem-
ber of the Berkeley County Board of Education,
Doctor Bernstein began practice there some 30
years ago.
He was a Past President of the Eastern Pan-
handle Medical Society, and was Chief of Staff
at City Hospital in Martinsburg.
Born in New York City, Doctor Bernstein was
graduated from Rutgers University in 1938 with
a B.S. degree, received a Ph.D. in bacteriology
in 1941 from Johns Hopkins University, and
his M. D. degree in 1949 from the University
of Utah.
He interned at Salt Lake County (Utah)
General Hospital, and took residencies at George
Washington University Hospital in Washington,
D. C., and at Newton Baker Veterans Administra-
tion Medical Center in Martinsburg.
A veteran of World War II, he was a
Diplomate of the American Board of Internal
Medicine.
Doctor Bernstein was a member of the
Eastern Panhandle Medical Society, West Vir-
ginia State Medical Association and American
Medical Association.
Survivors include the widow. Dr. Jean P.
Lucas, an internist at the Martinsburg VA Medi-
cal Center; four sons, Shawn Bernstein of
Washington, D. C.; Joel Bernstein of Corona
Del Mar, California; John Bernstein of Klamath
Falls, Oregon, and Ted Bernstein, at home; and
one daughter, Leigh Bernstein, at home.
* # #
JOHN C. GODLOVE, M. D.
Dr. John C. Godlove of Martinsburg, a
surgeon, died on February 11 in a Washington,
D. C.. hospital. He was 71.
A native of Martinsburg, Doctor Godlove was
graduated from Dickinson College in Carlisle,
The West Virginia Medical Journal
Pennsylvania, and received his M. D. degree in
1944 from the University of Maryland. He took
his postgraduate training in the Baltimore area.
A veteran of World War II, Doctor Godlove
was an honorary member of the Eastern Pan-
handle Medical Society, West Virginia State
Medical Association and American Medical As-
sociation.
Survivors include the widow; two daughters.
Linda Godlove of New York City and Mrs.
Tootie Ridenour of Williamsport (Grant
County); one son, John C. Godlove II of Harris-
burg, Pennsylvania, and one brother, Arnold
L. Godlove of Hagerstown, Maryland.
• « «
PETER D. CRYNOCK, M. D.
Dr. Peter D. Crynock, retired Morgantown
general practitioner, died on February 19. He
was 75.
Following service with the U. S. Army Medi-
cal Corps during World War II, Doctor Crynock
was a company doctor at the Koppers Coal
Company Mine at Grant Town in Marion
County, and later was company doctor with
Pursglove Coal Company and Christopher Coal
Company in Monongalia County.
After leaving mine practice, he entered pri-
vate practice in Morgantown, and was a staff
member of the former Vincent Pallotti Hospital
and at Monongalia General Hospital until his
retirement.
Doctor Crynock, w r ho was born in Dearth.
Pennsylvania, was graduated from West Virginia
University, and received a Doctor of Medicine
and Master of Surgery (M. D. C. M.) degree
in 1935 from Dalhousie University in Halifax,
Nova Scotia, Canada. He interned at institu-
tions in Nova Scotia. Doctor Crynock also
earned a degree in science from the University
of Virginia.
He held life memberships in the U. S. Military
Surgeons and the U. S. World Medical Associa-
tion; was a member of the Dalhousie Alumni
Association and its Emeritus Club; held a fel-
lowship in the Royal Society of Health, Patron
of her Majesty the Queen, in London, England;
and was an honorary member of the Monongalia
County Medical Society, West Virginia State
Medical Association and American Medical As-
sociation.
Survivors include the widow; one brother,
John E. Crynock of Morgantown, and five sisters,
Anna Crynock, Mary Sypolt, Susan Crynock and
Kathryn Crynock, all of Morgantown, and Emily
Crynock of Chicago.
County Societies
McDowell
The McDowell County Medical Society met
on February 9 at Stevens Clinic Hospital in
Welch.
The American Medical Association video
cassette program on dizziness was presented.
The meeting was preceded by a social hour
and covered-dish dinner provided by the
Auxiliary. — John S. Cook, M. D., Secretary.
« # «
FAYETTE
The Fayette County Medical Society met on
February 2 at the Plateau Medical Center in
Oak Hill.
The guest speaker was Dr. Hassan Amjad of
Beckley. His topic was “Cancer of the Lung.”
— Serafino S. Maducdoc, Jr., M. D., Secretary-
Treasurer.
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April, 1983, Vol. 79, No. 4
xix
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Reprinted from The West Virginia Medical Journal, September 1981
Your Association’s Professional Liability Insurance Program Includes:
• A five-year market guarantee with Continental Casualty Company,
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The West Virginia Medical Journal
Vol. 79, No. 5 May, 1983
Hypokalemic Myopathy In Hyperemesis Gravidarum:
Its Historical Significance*
JACK E. RIGGS, M. D.
Department of Neurology, West Virginia University
School of Medicine, Morgantown
ROBERT C. GRIGGS, M. D.
Department of Neurology, University of Rochester
School of Medicine and Dentistry, Rochester,
New York
LUDWIG GUTMANN, M. D.
Department of Neurology, WVU School of Medicine
The occurrence of hypokalemic myopathy in
a iv oman with hyperemesis gravidarum is re-
ported. Although previously unrecognized ,
hypokalemic myopathy may have been a rela-
tively common cause of weakness in some cases
of hyperemesis gravidarum.
■\J"USCLE weakness complicating pregnancy was
a well-recognized occurrence during the
nineteenth century. In von Hosslin’s review of
494 such cases the causes of weakness included
trauma, infection, focal neuropathies, and
polyneuropathies. 1 The polyneuropathy develop-
ing during pregnancy was referred to as the
polyneuritis of pregnancy, accounting for ap-
proximately 10 per cent of the cases in von
Hosslin's review . 2
As early as 1889, an association was noted
between hyperemesis gravidarum and the
polyneuritis of pregnancy, 3 and this subsequently
was firmly established. 2 Since hyperemesis
gravidarum initially was thought to represent
a toxic manifestation of pregnancy, it was
“Presented in part at the 34th Annual Meeting of the
American Academy of Neurology, May 1, 1982, Wash-
ington, D. C.
hypothesized that the polyneuritis of pregnancy
had a similar etiology. 2 However, due to patho-
logical and clinical similarities, the polyneuritis
of pregnancy has been considered a nutritional-
deficiency polyneuropathy since the 1930s. 46
In some cases of the polyneuritis of pregnancy,
however, sensory abnormalities and decreased
reflexes were conspicuously absent, and a much
more rapid resolution of motor weakness
occurred following abatement of the hyperemesis
than would have been expected with a neuro-
pathy. 2 This suggests that in at least some cases
of hyperemesis gravidarum there may have been
a mechanism of motor weakness other than
polyneuropathy.
We now report a case which may shed some
retrospective insight into the association between
motor weakness and hyperemesis gravidarum.
Case Report
A 27-year-old. gravida 4, para 1, abortus 2,
four-month pregnant woman was referred for
neuromuscular evaluation because of progressive
muscle weakness and an elevated creatine kinase
(CK - 1156 IU/ml, nl 7-89 ). Previous medical
history w r as unremarkable. The only medication
on admission was a daily vitamin tablet.
Her pregnancy had been complicated by per-
sistent nausea and vomiting for three months.
She had been vomiting 10 to 12 times per day
during the two weeks preceding her hospital
admission. Four weeks before admission, she
noted tenderness of her thigh muscles and diffi-
culty climbing stairs and lifting her arms above
her head. She became so weak that her husband
May, 1983, Vol. 79, No. 5
95
Figure. Biceps muscle. Composite demonstrating
rare isolated vacuolated muscle fibers (modified
Gomori trichrome, X126).
had to carry her about their home. She had
lost 13 pounds during her pregnancy. There
was no history of fever, joint symptoms, skin
rash, or dark urine.
On admission she was very thin. Her abdomen
was soft and the uterus was palpable below the
umbilicus. Bowel sounds were present. General
examination was otherwise unremarkable. Muscle
hulk was slender and tone was normal. Her
thigh muscles were tender to palpation. She
was unable to lift her head off the bed when
supine, squat, or step up onto an eight-inch stool.
Muscle strength ( Medical Research Council
Scale) was grade 4- to 4 proximally except for
the neck flexors (grade 2) and hip flexors
I grade 3). The remainder of the neurologic
examination, including reflexes, was normal.
Laboratory Studies
Admission laboratory studies showed: K - 1.9
mEq/L, Na - 140 mEq/L, CO? - 25 mEq/L.
Cl - 103 mEq/L, BUN - 5 mg/dl, Hct - 31 per
cent, CK - 1580 IU/L (MB fraction negative),
LDH - 269 IU/L (nl 100-225), and AST - 116
IU/L (nl 7-40). Urine was negative for
hemoglobin and myoglobin. Thyroid, renal.
adrenal, liver, immunologic, and other electro-
lyte studies were normal. Electrocardiogram
showed changes consistent with hypokalemia.
Treatment and Results
After admission, 200 mEq of oral potassium
chloride (K-lyte/Cl R ) was administered over
eight hours, at which time serum K had risen
to 3.3 mEq/L. Her strength improved rapidly
during the first two days after admission. EMG
studies two days after admission were normal.
Left biceps muscle biopsy done three days
after admission demonstrated a mild vacuolar
myopathy (Figure). Eight days after admission.
CK was 21 IU/L. One month after admission
her strength had returned to normal. Her vomit-
ing ceased immediately after the hypokalemia
was corrected and did not recur (see Table for
clinical and laboratory summary). The patient
gave birth to a normal baby girl five months
after admission. A diagnosis of hypokalemic
myopathy complicating hyperemesis gravidarum
was made.
Discussion
In 1951. Bergquist first reported the occur-
rence of hypokalemia in hyperemesis gravidarum
and speculated that potassium deficiency was
responsible for the associated muscle weakness
in his case.' He also suggested that motor weak-
ness present in some previously reported cases
of the polyneuritis of pregnancy may actually
have been related to potassium deficiency pro-
duced by the persistent vomiting in hyperemesis
gravidarum." Appearing soon were two ad-
ditional reports also describing muscle weakness
in hyperemesis gravidarum with associated
hypokalemia. 8,9 In these cases, rapid improve-
ment of muscle strength followed correction of
the hypokalemia. 8 ' 9 In 1955, significant hypo-
kalemia was reported in nine of 10 women with
hyperemesis gravidarum, suggesting that hypo-
kalemia is usually present in hyperemesis
gravidarum. 10
TABLE
Clinical and Laboratory Summary
CPK (IU/L), nl 7-89
K(mEg/L), nl 3. 5-4. 5
Vomiting
Weakness
1 day before admission
1156
2.0
present
severe
Admission
1580
1.9
present
severe
6 hours after admission
-
1.7
present
severe
11 horns after admission
-
3.3
absent
moderate
2 days after admission
-
3.6
absent
moderate
4 days after admission
202
3.8
absent
mild
8 days after admission
21
3.8
absent
minimal
1 month after admission
-
-
absent
none
96
The West Virginia Medical Journal
Although hypokalemia has been associated
with hyperemesis gravidarum, a specific my-
opathy in hyperemesis gravidarum has not been
previously identified as a cause of weakness.
Hypokalemic myopathy in man initially was
reported in 1955. the same year as the last report
to note specifically hypokalemia in hyperemesis
gravidarum. 10 This coincidental disappearance
of motor weakness from the hyperemesis
gravidarum literature and the initial description
of hypokalemic myopathy presumably is related
to improved obstetric fluid, electrolyte, and
nutritional management. This case provides the
first documentation that hypokalemic myopathy,
in addition to nutritional neuropathies, may be
a cause of muscle weakness in hyperemesis
gravidarum. Hyperemesis gravidarum previously
has not been associated with hypokalemic
myopathy. 12
Due to the incidence of hyperemesis gravi-
darum I about one case per 1.000 births) 13 and
the frequent significant hypokalemia in hypere-
mesis gravidarum, 10 hyperemesis gravidarum
may have been a relatively common, although
previously unrecognized, cause of hypokalemic
myopathy. Conversely, hypokalemic myopathy
may have been a relatively common, although
previously unrecognized, cause of weakness in
some cases of hyperemesis gravidarum.
Generic drug listing : potassium chloride
iK-lyte/Cl R ).
References
1. von Hosslin R: Die schwangerschaftslahmungen
der mutter. Arch fur Psych Nervenkrank 1904; 38:730-
861 & 1905; 40:445-576.
2. Berkwitz NJ, Lufkin NH: Toxic neuronitis of
pregnancy: A clinicopathological report. Surg Gynecol
Ohstet 1932; 54:743-757.
3. Whitfield DW: Peripheral neuritis due to the
vomiting of pregnancy. Lancet 1889; 1:627-628.
4. Strauss MB, McDonald WJ: Polyneuritis of preg-
nancv: A dietary deficiency disorder. JAMA 1933; 100:
1320-1323.
5. Luikart R: Avitaminosis as a likely etiologic factor
in polyneuronitis complicating pregnane)', with the re-
port of a case. Am J Ohstet Gynecol 1933; 25:810-815.
6. Theobald GW : Neuritis in pregnancy successfully
treated with vitamin Bl. Lancet 1936; 1:834-837.
7. Bergquist N: Potassium deficiency in hvperemesis
gravidarum. Acta Ohstet Gynecol Scand 1951; 30:428-
438.
8. Lans HS, Gollin HA, Daro AF, Nora E: Hypo-
kalemia due to persistent vomiting during pregnancy.
JAMA 1953; 153:1012-1015.
9. Romney SL, Merrill JP, Reid DE: Alterations of
potassium metabolism in pregnancy. Am J Ohstet
Gynecol 1954; 68:119-130.
10. Fitzgerald JPB: Potassium depletion and replace-
ment in hyperemesis. New Zealand Med J 1955; 54:36-
50.
11. Achor RWP, Smith LA: Nutritional deficiency
syndrome with diarrhea resulting in hypopotassemia,
muscle degeneration and renal insufficiency: Report of
case with recovery. Mayo Clin Proc 1955; 30:207-215.
12. Penn AS: Myoglobin and myoglobinuria, in
Vinken PJ, Bruyn GW (eds): Handbook of Clinical
Neurology , Amsterdam, Elsevier/North-Holland Biomedi-
cal Press, 1979; 41:259-285.
13. Fairweather DVI: Nausea and vomiting during
pregnancy. Ohstet Gynecol Annu 1978; 9:91-105.
i/i
3
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5
May, 1983, Vol. 79, No. 5
97
Diagnosis And Treatment Of Alzheimer's Disease
M. K. HASAN, M. D.
Psychiatrist, Division of Behavioral Sciences and Psy-
chiatry, Beckletj Appalachian Regional Hospital, Beck-
ley, West Virginia; and Assistant Clinical Professor,
Department of Psychiatry, Marshall University School
of Medicine, Huntington, West Virginia
NANCY L. SLACK, A.C.S.W.
Social Worker, Division of Behavioral Sciences and
Psychiatry, Beckletj Appalachian Regional Hospital
ROGER P. MOONEY, M.A.
Clinical Psychologist, Division of Behavioral Sciences
and Psychiatry, Beckletj Appalachian Regional Hospital
By the year 2030, 25 million of the estimated
55 million elderly will be 75 years of age and
older. The major health problem facing this
group is dementia. If this trend continues,
dementia will be third only to cancer and heart
disease as a cause of mortality and morbidity in
this group. Approximately four million people
65 and older have dementia of the Alzheimer's
type.
In this paper, the features of Alzheimer's
disease and the various diagnostic tools are dis-
cussed. The authors compare the disease process
with the depressive illness, keeping in mind that
dementia is a clinical diagnosis. Recommenda-
tions for maintenance and treatment are pro-
vided.
Tr is estimated that 11 per cent (25 million)
of the U. S. population is over 65 years of
age; however, this group accounts for 30 per cent
of all personal health care spending and 55 per
cent of all federal health dollars. It is further
estimated that of the 287 billion dollars spent
annually for personal health care, approximately
75 billion is for the elderly, especially those 75
and over. This, by far, is the most rapidly
growing segment of the population. By the year
2030, 25 million of the estimated 55 million
elderly will be 75 and older.
While growth of this segment is taking place
at an amazing rate, knowledge of the aging
process, including the diagnosis, ramifications
and treatment of its diseases, is being assimilated
all too slowly. “Ageism," prejudice against the
elderly, is common and rampant among all pro-
fessionals including physicians. “Ageism" con-
tributes to the frustration that “nothing can be
done” or “nothing should be done." Treatment
is seen as an “unworthy investment of time and
effort. These attitudes often encourage hostility,
paranoia, depression, abandonment and indif-
98
ference, and have been linked to “familial
elderly abuse.” This is a sinister situation which
poses a serious dilemma to care providers who
have turned increasingly to the family as “the
last line of defense in the care of the aged."
The country's nursing home expenditures have
been rising at an annual rate of 16 per cent.
Today, with 1.3 million people in nursing homes,
the spending level is nearing $22 billion; by
1990. it is estimated to reach $75 billion. By
that time nearly 10.300 geriatricians will be
needed as consultants and, in complex cases, as
primary care practitioners. According to a 1977
American Medical Association survey, fewer
than 700 physicians identified themselves as
having a primary, secondary, or tertiary specialty
in geriatrics.
Research Lags
Fifteen per cent of people age 65 years and
over have some form of psychiatric impairment
and. of these, three per cent require institu-
tionalization. Five per cent of people age 65
and older, approximately four million, have
dementia of the Alzheimer's type, a disorder
that is marked by progressive mental deteriora-
tion of memory and judgment. Of these, one
million are so severely affected that they cannot
manage themselves. Despite the severity of the
problem, only $16 million was spent on dementia
research last year, as compared to the $22 billion
spent in nursing homes.
Alzheimer’s disease, a form of primary
neuronal degeneration, was first described by
Alzheimer, in 1907, in a 51-year-old female.
The female died four and one half years later,
and the classical histopathology was determined.
It is the most common form of irreversible
dementia, accounting for 50 to 70 per cent, as
opposed to multi-infarct dementia, which repre-
sents 15 to 20 per cent.
Early diagnosis of Alzheimer’s is essential and
of paramount importance because treatment
differs. I nfortunately. referral is often too late
or delayed; consequently, the illness has pro-
gressed too far for any improvement. This has
a detrimental effect on the family and their
morale, as well as on the community. In turn,
feelings of rejection in the patient and his
further deterioration occur due to poor manage-
ment. Paradoxically, it has been shown that
differentiation is easier in the earlier stages of
the disease, thereby allowing more humane,
The West Virginia Medical Journal
compassionate, and cost-effective treatment, pre-
ferably at home by caring relatives and
neighbors.
In this paper, the authors discuss the clinical
features of Alzheimer’s disease, the various
diagnostic tools, and compare the disease process
with the depressive illness. The authors also
provide recommendations for maintenance and
treatment.
Diagnosis
To establish a diagnosis of Alzheimer’s disease,
a biopsychologieal. social approach which entails
a life history of the patient is necessary. A
thorough physical examination, including a
detailed drug history, is essential. The following
laboratory examinations are recommended in
all cases of suspected Alzheimer’s disease:
— CBC
— Electrolytes
— SMA 12
— EKG
— Serology
— Urinalysis
— Ti
— Dexamethasone Suppression
Test (a level of over 6 /rg/dl of
serum cortisol is indicative of a
depressive illness)
—Serum Magnesium (as excessive
use of laxatives or antacids can
lead to magnesium toxicity)
— EEG (if the EEG appears worse
than the mental state, then
dementia is likely to be
secondary rather than indicative
— Serum Aluminum 0 f Alzheimer’s disease)
— Psychological Tests _ 0ccult Blood Stool x 3 days (to
Chest X-ray detect occult cancers, especially
— CT Scan of the colon)
— TSH
— Serum B12
— Folic Acid
A thorough evaluation may be expensive on
a short-term basis; however, it is cheaper in the
long run, especially if an early diagnosis reveals
a treatable condition. It is estimated that 20 to
25 per cent of the patients diagnosed as having
organic brain syndrome ( OBS ) have a causative
factor which is treatable, resulting in ameliora-
tion of the symptoms. Tests can he completed
on an outpatient basis.
Another essential diagnosis to be included
and excluded in all cases of dementia is depres-
sion, which can mask chronic OBS. In our
practice we assume that all patients suffering
from dementia have depression unless proven
otherwise. When the dementia is accompanied
by psychomotor retardation, the possibility of
depression or multi-infarct dementia should he
explored. With depression, the onset is sudden
and the patient is better at night. The depressed
patient tends to surrender to the disability,
whereas the demented patient fights it. When
depression is treated successfully, immense
gratification and reward are by-products to all
concerned.
Kiloh 1 emphasized the danger of relying on
psychological testing for diagnostic purposes.
Some of his patients on psychometric testing
showed alterations typical of organic deteriora-
tion: normal restitution was attained after treat-
ment of depression. Similarly, CT scans showing
cerebral atrophy could not be judged as a sign
of dementia. Cerebral atrophy is ubiquitous
after the age of 50, even in intellectually intact
persons. Dementia is a clinical diagnosis, and
a holistic approach is essential. The single best
diagnostic tool is the mental status.
After the diagnosis of Alzheimer’s disease or
dementia has been made, the family is faced
with several decisions. If the person has been
living alone, can he or she continue in that
situation? Another frequent uncertainty is the
ability of family members to care for the patient
TABLE 1
Comparison of the Clinical Features of Alzheimer’s Disease with Other Organic Brain Syndromes
A. Early Phase
Alzheimer’s Disease
Non- Alzheimer’s
Disease
I. Memory Loss
Early, insidious, patient becomes less spontaneous, is irri-
table, seeks and prefers familiar surroundings, may go
unnoticed by relatives, covers up his loss, may show
“catastrophic reaction’’
Late
II. Precipitating Factors
May be present during bereavement, children leaving
home, etc.— any situations involving interruption of the
patient’s daily routine
Less Often
III. Apraxia
Early, but after memory loss, may present as dressing
apraxia or inability to arrange objects in space
Late
B. Intermediate Phase
Emotional lability, shallow affect, irritability' and insensi-
bility, increasingly self-absorbed, speech may be affected,
needs management in specialized services, as banking, etc.
Also Seen Here
C. Late Phase
Market changes in personality, confabulation, incontinence,
preservation of social competence, hematological signs
present, may show psychotic features and neurological
deficits
Early
May, 1983, Vol. 79, No. 5
99
TABLE 2
Comparison of the Clinical Features and the Aspects of Treatment of Depression and Dementia.
Depression
Dementia
Age
Earlier
Late, usually after 75
Onset
Recent, rapid, following a precipitating
event, may regress and may become vege-
tative
Insidious, no broad linkage to a precipita-
ting event, happier and active
Past History
Of depression with behavior disturbance
Absent
Family History
Of depression
Of dementia
Memory Loss
Complains bitterly of memory loss which is
generalized, poor concentration, puts no ef-
fort in answers, gives in easily and says, “I
don’t know.”
Rarely complains, covers up memory loss
Affect
Pervasive, depressed
Emotional lability, appears happier in gen-
eral, shallow, may show depressive content
in early part of the disease
Treatment
DST, trial of antidepressants (adequate dose
for 3-6 weeks), psychotherapy (especially
cognitive therapy)
Supportive psychotherapy involving the indi-
vidual, family and significant others
Miscellaneous
Family less tolerant of global disinterest
Family tolerant of forgetfulness and often
say, “It’s his age.”
Other features of depressive illness present
Absent
Seek treatment earlier
Avoid treatment
in their homes. These questions need to be dis-
cussed with those who know the patient well.
The primary care physician and the family are
in the best position to deal with these concerns.
Recommendations
At the present time there are no hard and fast
rules on how to care for the patient, only recom-
mendations. In each case consideration should
be given to the individual needs of the people
who are involved and the practicality of the
situation.
A. Medical
1. The primary care physician should
avoid polypharmacy and schedule
periodic physical assessments.
2. Medication needs to be kept to a
minimum, and nutrition, hydration
and constipation need to be monitored.
3. The presence of depression as a
psychiatric syndrome as well as other
psychiatric syndromes should be thor-
oughly evaluated.
4. The primary care physician needs to
attend to other physical or mental
disorders.
5. The use of neuroleptic drugs and.
in some instances, electro-convulsive
therapy, may eliminate the depressive
features. Antidepressants with the
least anticholinergic side effects are
recommended in low doses.
6. Cerebral vasodilators are valueless.
7. Hydergine, an ergot alkaloid, has been
shown to be beneficial in a small num-
ber of selected cases, especially in the
early phase.
8. Lecithin, choline, and physostigmine
have shown controversial and un-
impressive results.
B. Psychosocial
1. In the early stages of the disease, the
patient may be able to continue his
personal hygiene as usual: however, in
the middle and latter stages, he may
need assistance. Clothing choices
should be kept to a minimum, and old
clothing or clothing of the wrong size
should be discarded. Allow the patient
to do as much of his personal hygiene
as possible, and assist when necessary.
2. Incontinence often is frustrating to the
family. Initially, loss of bladder con-
trol may occur only occasionally; how-
ever. as the disease progresses it may
become more frequent. Regular at-
100
The West Virginia Medical Journal
tendance to the bathroom, restricting
fluids in the evening, and going to
the bathroom before bedtime should
be done routinely. When needed,
adult-size diapers may be used. Avoid
fecal impaction by regular toilet-
training, well-balanced meals with high
fiber content, prune juice, and Meta-
mucil.® Fecal impaction can be a
cause of confusion.
3. Regular sleep hygiene should be en-
couraged. Daytime napping and sleep-
ing aids should be avoided. Where
needed, use L-Tryptophan (a natural
amino acid present in milk, cheese,
fish, etc.) in a dose of 1000-1500 mg.,
given 1-2 hours prior to bedtime.
4. Regular exercise when possible (e.g.,
a daily walk with supervision) is
strongly advised.
5. As the disease progresses, the patient
becomes increasingly forgetful and
shows signs of memory impairment,
especially for recent events. He may
need gentle reminders to do things he
previously did routinely. Articles such
as glasses and dentures may become
misplaced. The family may need to
take the responsibility of placing the
dentures and glasses in a certain place
at night and giving them to the patient
in the morning. Orienting the patient
to time, place and the other person (s)
present also will reduce stress. This
can be done, for example, by saying,
“We will now go into the kitchen for
lunch. Visitors, including family
members, should be introduced by
name.
6. In many communities there are volun-
tary groups (The Alzheimer Society)
whose members share their common
experiences in caring for persons with
Alzheimer’s disease. The group pro-
vides information on new advances
made in research, and services that are
available; however, the most important
aspect of the group is that of emotional
support for its members. It is the
common sharing that boosts the mem-
bers’ morale.
Summary
WTiereas the life expectation for patients suf-
fering from dementia used to be two to three
years, advancements in medicine now have ex-
tended it to 10 years. Dementia has become a
major health problems and, if the trend continues,
will be third only to cancer and heart disease
as a cause of mortality and morbidity by the
year 2000.
Economists may question the cost-effectiveness
of providing expensive and demanding services
to those who will never be productive members
of society again, but health care cannot be
measured in dollars alone. The quality of life
is important; and, if we can improve this by
rehabilitative and diversional facilities, the
authors believe the money is well spent. Un-
fortunately, in the authors’ opinion, some of the
blame for inadequate care for the elderly can
be leveled at the U. S. Health Care Financing
Administration, which controls Medicare and
emphasizes “cost containment’’ above all else.
Many insurance carriers conform to the guide-
lines of Medicare. Although Medicare re-
imburses medical and surgical services at 80
per cent of all customary and reasonable fees with
no yearly maximum, it reimburses only 50 per
cent and up to $250 per year for psychiatric
consultation and care. This has resulted in
inappropriate use and overuse of psychotropics
with some deleterious effect. This may appear
cheaper in the short run, but the resulting in-
crease in morbidity and mortality adds signifi-
cantly to long-term care, to say nothing about
the tragic waste of human potential.
New Programs Will Be Needed
Research into the cause and treatment of
Alzheimer’s disease and similar diseases is being
conducted throughout the country. Ultimately,
prevention and treatment will be the answer.
Until this can be accomplished, however, the
care and management of a person with these
diseases will be a major concern of families and
health care providers. Health and social pro-
grams will have to be developed and expanded
to meet these needs.
Presently, there are several programs being
utilized throughout the country which deserve
further attention. Day care for the elderly is
similar to the day care programs for children;
however, the providers are specifically trained in
the needs of geriatric persons. This allows the
family members to continue employment while
being reassured that the elderly relative is
being looked after. Also, home care programs
and tax breaks are being explored to provide
financial incentive to the family members for
keeping elderly persons at home. Both of these
programs, and others, should be further de-
veloped, and the need for them documented.
May, 1983, Vol. 79, No. 5
101
Each concerned person has a right, and some-
what of a responsibility, to let the policy
makers know that the need exists. Not until
enough people do so will improved and new
programs become a reality.
References
1. Kiloh LG: Pseudodementia. Acfo Psychiatr Scand
1961; 37:336-351.
2. Larsson T, Sjogren T, Jacobson G: Senile de-
mentia: A clinical, sociomedical and genetic study. Acta
Psychiatr Scand 1963; Suppl 39.
3. Perl DP, Brody AR: Alzheimer’s disease: X-ray
spectrometric evidence of aluminum accumulating in
neurofibrillary tanglebearing neurons. Science 1980; 208:
297-299.
4. Schneck MK, Reisburg B, Ferris SH: An overview
of current concepts of Alzheimer’s disease. Am J Psy-
chiatry 1982; 139:165-173.
5. Wells CE: Management of dementia in congenital
and acquired cognitive disorders, in Katzman R (ed):
Dementia , New York, Raven Press, 1979, p 281.
6. Acute confusion, depression are misdiagnosed as
senile dementia. Clin Psychiatry News , March, 1982,
p 31.
7. Alzheimer’s psychometric deficits correlate with
brain changes. Clin Psychiatry News , March, 1982, p 1.
8. Brain changes correlate with psychometric loss in
dementia. Clin Psychiatry News, March, 1982, p 26.
9. Clinical acumen ultimate basis for subcortical de-
mentia diagnosis. Clin Psychiatry News, March, 1982,
P 7-
10. Dementia major health problem with mortality
decline in elderly. Clin Psychiatry News, March, 1982,
p 15.
11. National Center for Health Statistics: The pro-
jection of the population of the United States, 1975-2050,
in Census Bureau Current Population Reports Series, 601.
Washington, DC, US Government Printing Office, 1975,
p 25.
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the first or title page should be shown the title of the article, the name (or
names) of the author, and his degrees. Pages should be numbered consecu-
tively, the page number being shown in the right upper corner along with
the surname of the author.
Where reference is made to generically-designated drugs, the first such
reference must be followed by parentheses containing the most commonly
known trade-name drug of that designation. In addition, a listing of all generic
drugs mentioned in the article, with their trade-name equivalents, should
appear at the end of the article.
A short abstract summarizing the manuscript should be included. This
should be typed in double space on a separate page.
Authors are requested to submit a carbon copy with the original.
Illustrations should be numbered and their approximate locations shown
in the text. Each should be identified by placing on its back the author’s
name, its number and an indication of its “top.” Drawings and charts in-
tended for reproduction should be done in black (India) ink on pure white.
Photographs should be on glossy paper and minimum of about 5 by 7 in.
in size. Cost of printing black and white photos in excess of 4 will be billed to
author, and no more than 25 references will be published free of charge
to the author. A legend should be provided for each illustration and, preferably,
attached to it.
All scientific material appearing in The Journal is reviewed by the
Editorial Board. Manuscripts should be mailed to The Editor, West Virginia
Medical Journal, Box 1031, Charleston, W. Va. 25324.
102
The West Virginia Medical Journal
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THE ‘COST CONTAINMENT' (?) BILL
T his month, I intended to discuss involve-
ment, but after visiting Greenbrier Val-
ley and Wetzel County Medical Societies,
there were many questions on the so-called
hospital cost containment bill. I would like
to address it this month, with involvement
to come in the future.
We must first realize “cost containment”
is a misnomer for the legislation enacted in
the last 16 minutes of the 60th day of the
Legislative Session. The bill actually estab-
lishes a three-member authority to regulate
and limit rates hospitals can charge but does
not address any costs incurred by hospitals.
Interestingly enough, the funding for this bill
is borne by the hospitals themselves, thereby
increasing their costs. This is reminiscent of
medieval times when a condemned person
was forced to pay for his own executioner in
order to assure a swift and merciful death.
Before this authority has even met, hos-
pital rates have been frozen at the level of
February 1, 1983, regardless of any increases
in costs for goods and services hospitals may
have acquired since that time. In addition,
the bill mandates a 12-per cent cap on in-
creases in gross revenue for hospitals. Any
funds in excess of this 12 per cent will go to
the board itself with no indication as to how
these monies are to be spent. Unfortunately,
this provision is retroactive to the hospital’s
last reporting period. This means that if the
hospital’s fiscal year ended prior to the
effective date of this legislation, then the 12-
per cent cap could be on 1981 or 1982
revenues.
Many hospitals already may have exceeded
those older limits through expanded services
and offering improved care. This new legis-
lation does not recognize these exceptions.
The money is due now. This appears to me
to be confiscation, not even an acceptable
form of taxation. I am unaware of any other
industry in our state which must turn over to
a state-appointed bureaucracy a percentage
of its gross revenue, not its profits.
Perhaps, if this legislation sets a precedent,
the State Highway Department and the De-
partment of Motor Vehicles will set the same
sort of cap on the revenues of the automobile
dealers in our state and, by confiscating their
money, could obtain the funding to fix the
roads. In this example, one thing is for sure:
there would be a lot fewer automobiles using
those roads.
The bill also allows the rate regulators to
have jurisdiction over the professional
charges of a hospital-based physician under
contract to a hospital. I do not feel that it
would be advantageous to our attempts to
attract top-flight radiologists, anesthesi-
ologists, pathologists and emergency room
physicians to West Virginia to have to inform
them that their professional fees will be set
in advance by a bureaucratic agency of the
state government. Indeed, I wonder if we
can retain some of the ones we now have.
As you have probably noticed, I do not like
any part of this law. The original intent may
have been good, but I feel it was an ill-
conceived and politically motivated act
which was passed in the closing moments of
the session by political pressure, and possibly
was poorly understood by a majority of the
members of the legislature. I feel it will be
detrimental to the quality of medical care
of our citizens, as the regulators are given the
authority to determine the “quality of care”
without any representation or any input
from the medical profession.
I fear in the future this will be considered
the “Mandolidis decision” for the health care
industry in our state. Down the road a few
years we will need the same type of bail-out
to recover from its effects as industry in our
state received this year. Unfortunately, by
then it may be far too late for many of our
hospitals and physicians.
n
/
Ql
Harry Shannon, M. D., President
West Virginia State Medical Association
104
The West Virginia Medical Journal
The West Virginia ttedical Journal
Editorials
The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or
in communications submitted to this Journal for publication. The author shall be held entirely responsible.
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State
AJ\edical Association.
Now that we all know all about DRGs ( see
editorial in April issue of The Journal l, let's
talk about some interesting related issues.
Diagnostic Related Groups are the basis for a
prospective method of hospital payment for
Medicare patients.
We have mentioned that hospital admini-
strators are worried about DRGs. They feel
vulnerable to manipulation by staff members who
might threaten to run up
MORE ON DRGs costs if certain whims and
desires are not satisfied. Ad-
ministrative control over diagnostic enthusiasm
is simply not present under our current system.
As a matter of fact, it would have been silly for
hospital administrators to even think of such
control as long as no one questioned payment
on the basis of cost.
Things are different now. A cost basis of
payment is out because it leads to cost escalation.
Prospective payment is in because costs can be
budgeted and controlled.
How to get a handle on control of clinical
costs is the problem now facing hospital admini-
strators. One method is through utilization
review. This has been tried under the old cost
basis payment method and found to be of limited
use. It will be tried again with more vigor.
Another way is somehow to close and exercise
more control over medical staffs. Surplus num-
bers of physicians make this an attractive pos-
sibility but altering medical staff bylaws to
accomplish it might be difficult.
A sure way to control clinical costs is to have
salaried physicians. They make money or they
are fired. Have you noticed hospitals in your
area employing physicians in newly created
positions recently?
There is absolutely no question that the sur-
vival of some hospitals is at issue. With or with-
out the wholehearted cooperation of staff physi-
cians, some hospitals are likely to go under as
a result of financial pressures brought to bear
by DRG prospective pricing.
What if too many hospitals go under? What
if three hospitals in Charleston go under, or two
in Wheeling or two in Huntington? What would
be the medical consequences of such a tragedy?
What would he the political consequences?
These are not idle questions. It is being pro-
posed that great risks be taken with our medical
care system. Where is the safety net in this high
wire act? Where are the life rafts if this ship
won’t float?
Prospective hospital payment plans using
DRGs hold great promise. We do not know
whether any plan yet proposed will work. The
concept merits testing but not full support. Not
yet.
We have all heard tales about how this or
that health care system is good or bad. The
tale is usually followed by an important excep-
tion, such as “the system is poor, but my doctor
is good." There is no health care system that
pleases all, nor will there
THE PATIENT, ever be. The marketplace
OR THE SYSTEM? varies within the political
climate, and a framework is
produced that tries to serve the common good
To do what is best for society as a whole some-
times masquerades as being best for each indi-
vidual. This leads us to many irreconciliable
differences. A system that sacrifices individual
needs to more global needs cannot honestly and
consistently be represented as best serving my
needs or yours.
In such a climate, we try to serve a patient
whose individual needs must he paramount. Yet
our services must be tempered by the law,
the government, third-party payers, hospital
facilities and, indeed, the whole social fabric.
We commit ourselves to offering the best
diagnostic and therapeutic options for an indi-
vidual patient regardless of time or cost. Then
we must modify our suggestions based on some
larger perspective. The thread is lost in the
May, 1983, Vol. 79, No. 5
105
tapestry. Are we fooling ourselves? Are we
fooling our patients? Or are w T e all being fooled?
There is not one system so far and away
above all others that all others should cease.
Freedom of choice is a fine idea, but let it be
made clear that a commitment to one or another
health care system is not necessarily a commit-
ment to better health care for every individual.
That one individual will still depend upon
other individuals for proper care. The health
care system serves the people. We as physicians
serve the patient. — Stephen H . Franklin , M.D.,
in the Delaware Medical Journal.
I have read with special interest the article by Parkin-
son and Nerhood ["Special Article: Emergency Maternal
Transfer: An Ounce of Prevention for West Virginia
Newborns,” by Rosalind Parkinson, M. A.; and Robert C,
Nerhood, M. D., The Journal, January, 1983, Page 9] and
find several points to be either inaccurate or possibly in-
appropriately interpreted.
1. Based on the illustration presented in the article,
the present accelerated (if any) decline in infant mortality
began in the 60s, long before the organized effort toward
regionalization. It is not clear in the literature when or
why this trend began but it is clear that the increased
infant survival is related to multiple factors of which
the collaborative efforts to regionalize perinatal care is
only a single factor. The statement, “Much of the in-
creased infant survival is associated with collaborative
efforts to regionalize perinatal intensive care on a state-
wide basis,” certainly should be referenced since it states
an opinion.
2. The authors have grouped all hospitals other than
CAMC [Charleston Area Medical Center], Cabell-
Iluntington and West Virginia University into a single
category called Community Hospitals. This effectively
places all hospitals having between one and 1,600 births
in the same category and therefore introduces an initial
bias in any statistical analysis.
For instance [in the following Table], neonatal mortality
for the Raleigh General Hospital in Beckley for the years
1978-82 for infants weighing under 2,000 grams was
179.2/1,000 live births. This figure is equal to, if not
better than, that given for “perinatal centers.” During
this period, there was only one maternal transport, and
that in a patient with severe congenital heart disease and
a term gestation.
Table
Weight
#
births
Fetal
deaths
Neonatal
deaths
NND rate
500-999
63
26
16
432/1,000
1,000-1,499
42
12
11
366/1,000
1,500-1,999
128
11
6
51.2/1,000
Total
233
49
33
179/1,000
Further anal
lysis of
the above
Table show.
s that nine
of the 16 neonatal deaths in the 500-999 range weighed
under 750 grams.
3. The use of the 500 to 1,999-gram category prob-
ably is too all inclusive. These should be separated into
smaller weight categories. In 1978, 43 per cent of neonatal
deaths in West Virginia occurred in pregnancies ending
before the 28th week of gestation; 43.2 per cent weighed
less than 1,000 grams; and nine per cent, less than 500
grams.
4. The decision to undertake maternal transport may
be influenced in a negative direction by prior knowledge
of anomaly incompatible with life (54/311 in 1978), by
weight or gestational- age considerations or anticipated
labor-delivery intervals. Crude mortality rates include
these factors as a built-in bias.
5. The authors should use either neonatal mortality'
rates or infant mortality rates in a consistent manner.
Maternal transport is an important consideration; more
important, however, is the continuing upgrading of the
larger “community hospitals” to tertiary levels. This is
occurring and will, I think, predictably lower the number
of maternal and neonatal transports in the future. The
“expertise distance” between major medical centers and
quality “community hospitals” has narrowed appreciably
in the last decade, and will continue to do so in the
future.
Robert P. Pulliam, M. D. Elizabeth Bragg, R. N.
343 Westwood Drive Candidate. Masters Degree,
Beckley 25801 Maternity Nursing
Ohio State University
Research Methods Defended
( Editor’s Note: The following is in response to the
above letter.)
We welcome this opportunity' to address several im-
portant points included in Doctor Pulliam’s comments
about our study which suggests reduced mortality among
small infants is associated with maternal transfer to
perinatal centers.
Many hospitals of all sizes in West Virginia report data
which show very low mortality among small infants. In
some cases, the mortality rates are far below those for
perinatal centers. However, for purposes of analysis it is
necessary either to examine a large population of infants
or take a statistical sample of this group. This exercise
is important since rates calculated from small numbers
may be due more to chance than to any other identifiable
feature. In our study we used an entire population of
infants, and units of analysis were large enough for us to
note trends and/or associations with confidence.
Another important principle of investigation is the
careful justification of categories used in the analysis.
In our study we chose to compare infant outcomes be-
tween perinatal centers— hospitals staffed and equipped
to provide infant intensive care— and all other hospitals.
Subdivision of the latter group requires justification.
Should hospitals with equipment for infant intensive care
be examined separately? Should hospitals with associated
pediatricians become a separate category?
Doctor Pulliam suggests that size of a hospital’s birth
volume may be a good parameter. Our analyses in
separate studies of infant mortality by size of hospital
birth volume in West Virginia do not point to any clear
relationship between these variables. In fact, contrary to
Doctor Pulliam’s implied assumption that bigger hospitals
may have better outcomes, our preliminary results sug-
gest that there may be a negative association between
size of hospital birth volume and low infant mortality.
Full discussion of many of these issues may be found
in a recent article published after the acceptance of our
manuscript for publication in the Journal; a full review
of the extensive previous literature on this subject also is
included: Paneth N et ah: Newborn intensive care and
neonatal mortality in low-birth-weight infants: A popu-
lation study. N Engl J Med 1982; 307(3): 149.
Rosalind C. Parkinson, M.A.
Department of Community
Medicine, West Virginia
University School of Medicine,
Morgantown 2650C
Robert C. Nerwood, M.D.
Department of Obstetrics
and Gynecology. Marshall
University School of
Medicine, Huntington 25701
106
The West Virginia Medical Journal
GENERAL NEWS
FMG Educational Commission
Head Keynote Speaker
An authority in international medicine who
has held top posts at Johns Hopkins University
School of Medicine and in Beirut. Lebanon,
will be the keynote speaker for the State Medical
Association’s 116th Annual Meeting.
Dr. Samuel P. Asper, President of the Edu-
cational Commission for Foreign Medical Gradu-
ates f ECFMG ) in Philadelphia, will deliver the
Thomas L. Harris address during opening
exercises Friday morning, August 26. it was an-
nounced by the Program Committee. His topic
will be “Strengths and Weaknesses of the U. S.
Role in International Medicine.
The convention will be held August 25-27 at
the Greenbrier in White Sulphur Springs.
The ECFMG provides information to FMGs
about entry into graduate medical education and
health-care systems, and evaluates FMGs’ qualifi-
cations. The Commission, a non-profit organiza-
tion established in 1956, also gathers, maintains,
and disseminates data regarding FMGs.
The Annual Meeting will open with a pre-
convention session of the Association’s Council
and the first session of the House of Delegates on
Thursday morning and afternoon. August 25;
and end with the second and final House session
and reception for new Association officers on
Saturday morning and afternoon.
Dean of American University of Beirut
Doctor Asper, from 1973 until 1978, was
Dean of the School of Medicine of the American
University of Beirut (AUB), one of three over-
seas schools of medicine affiliated with Johns
Hopkins, and Chief of Staff of the American
University Hospital. Under his direction, the
AUB Medical Center held together during the
Lebanese civil strife of 1975-76, caring for
8,500 casualties. For his work in providing treat-
ment for the American community in Lebanon.
Doctor Asper received a citation in 1976 from
the then Secretary of State Henry A. Kissinger.
Doctor Asper, a native of Texas, has held his
present ECFMG post since June, 1982, and has
been Professor of Medicine at Johns Hopkins
since I960. He was graduated from Baylor L T ni-
versity, and received his M. D. degree in 1940
from Johns Hopkins. Following an internship in
medicine in the Johns Hopkins Hospital, he
began a fellowship in endocrinology at Harvard.
This was interrupted by World War II. during
which he served in the Harvard Medical L^nit
in Europe for nearly four years.
Following the war. Doctor Asper resumed his
fellowship for two years at Harvard, then re-
turned to Johns Hopkins. In endocrinology, his
work related to both clinical and research aspects
of the thyroid gland. As Associate Dean from
1957 to 1968. he guided postdoctoral activities
at Johns Hopkins, including the international
program, and coordinated Johns Hopkins’ affilia-
tion with the American University of Beirut.
ACP President
From 1967 to 1970. Doctor Asper. succes-
sively, was Vice President. President Elect and
President of the American College of Physicians,
Samuel P. Asper, M. D.
May, 1983, Vol. 79, No. 5
107
and, from 1970 to 1973, was Vice President for
Medical Affairs of the Johns Hopkins Hospital.
The 9 o'clock opening exercises Friday morn-
ing will precede the first general scientific ses-
sion, a “Symposium on Sexually Transmitted
Diseases' featuring four speakers. As announced
previously, two of the speakers will be Drs. Lee
P. Van Voris, Associate Professor of Medicine
at Marshall University, whose topic will be “Non-
Luetic, Non-Gonococcal Venereal Diseases,” and
George J. Pazin, Associate Professor of Medi-
cine, University of Pittsburgh, “Transmissible
Diseases of the Gay Patient."
Other subjects for the Friday morning session
will be syphillis and gonococcal infections; and
sexual mores in the 1980s.
The second and final general scientific session
will be held Saturday morning and, also as an-
nounced previously, will be a “Symposium on
Cardiovascular Diseases.” Individual subjects
will include new developments in the manage-
ment of cardiac arrhythmias; an update relative
to cardiovascular surgery; and the management
of congestive heart failure.
In addition to the general sessions, the Annual
Meeting agenda will include breakfast, luncheon
and other programs arranged by specialty
societies and sections, many of which also will
provide scientific discussions.
The specialty group meetings will be held in
large measure on Friday, with a few to be set
for Saturday morning, preceding the second
general session and at noon.
Doctor Adkins to be Installed
At the final House session on Saturday after-
noon, Carl R. Adkins, M. D., of Fayetteville will
he installed as the Association's 1983-84 Presi-
dent to succeed Harry Shannon, M. D., of
Parkersburg.
The Auxiliary to the State Medical Associa-
tion, with Mrs. Richard S. Kerr of Morgantown
the current President, as usual will hold its
meeting in conjunction with that of the Associa-
tion.
Members of the 1983 Program Committee
are David Z. Morgan, M. D., Morgantown,
Chairman; Doctor Adkins; Jean P. Cavender.
M. D., Charleston; Michael J. Lewis, M. D., St.
Marys; Kenneth Seller, M. D., Huntington, and
Roland J. Weisser, Jr., M. D.. Morgantown.
Additional information concerning speakers
and other convention details will be provided
in upcoming issues of The Journal.
Continuing Education
Activities
Here are the continuing medical education
activities listed primarily by the West Virginia
University School of Medicine for part of
1983, as compiled by Dr. Robert L. Smith,
Assistant Dean for Continuing Education, and
J. Zeb Wright, Ph. D., Coordinator, Con-
tinuing Education, Department of Community
Medicine. Charleston Division. The schedule is
presented as a convenience for physicians in plan-
ning their continuing education program. (Other
national, state and district medical meetings are
listed in the Medical Meetings Department of
The Journal. )
The program is tentative and subject to
change. It should he noted that weekly confer-
ences also are held on the Morgantown. Charles-
ton and Wheeling campuses. Further information
about these may be obtained from: Division of
Continuing Education, WVU Medical Center,
3110 MacCorkle Avenue. S. E., Charleston
25301: Office of Continuing Medical Education,
WVU Medical Center, Morgantown 26506: or
Office of Continuing Medical Education, Wheel-
ing Division. WVU School of Medicine, Ohio
\ alley Medical Center. 2000 Eoff Street. Wheel-
ing 26003.
May 7, Charleston. Outpatient Infectious Dis-
eases
May 20-21. Morgantown. Health Officers Con-
ference
June 3-4, Morgantown. Anesthesia Update '83
June 4, Charleston, 10th Annual Wildwater
Conference — Medical & Surgical Update
June 11, Morgantown, Interventional Radiology
Regularly Scheduled Continuing
Education Outreach Programs from
WVU Medical Center/
Charleston Division
Buckhannon , St. Joseph’s Hospital, first-floor
cafeteria, 3rd Thursday, 7-9 P. M. — May 19,
“Evaluation of Infertility and Frequent Spon-
taneous Abortions," Bruce L. Berry, M. D.
June 16, “Sudden Infant Death Syndrome,”
David Myerberg, M. D.
108
The West Virginia Medical Journal
Cabin Creek , Cabin Creek Medical Center,
Dawes, 2nd Wednesday, 8-10 A. M. — May
11, "Hypertension Update,” Steven Grubb,
M. D.
Gcissaway, Braxton Co. Memorial Hospital, 1st
Wednesday, 7-9 P. M. — May 4, “Manage-
ment of Trauma in the Small Hospital Setting
and During Transport.” Paul Derboven, M. D.
June 1, "Common Blood Disorders,” Steven
Jubelirer, M. D.
July 6, “The Pharmacology of Hypertension
Management," Stephen Grubb. M. D.
Aug. 3, “Diagnosis of Pulmonary Disorders,”
Dominic Gaziano. M. D.
Madison, 2nd floor, Lick Creek Social Services
Bldg., 2nd Tuesday, 7-9 P. M. — May 10.
“Common Dermatological Problems,” Stephen
K. Milroy, M. D.
June 14, “Recently Recognized Sexually —
Transmitted Diseases,” Thomas W. Mou,
M. D.
July 12, “Approach to the Peripheral Vascular
Patient," Ali F. AbuRahma, M. D.
Oak Hill, Oak Hill High School (Oyler Exit, N
19 1 4th Tuesday, 7-9 P. M. — May 24,
“Pharmacology & Clinical Use of Calcium &
Beta Blockers," Robert Hoy, Pharm. D.
W elch, Stevens Clinic Hospital, 3rd Wednesday,
12 Noon-2 P. M. — May 18. “Gastro-
intestinal Bleeding,” Warren Point, M. D.
Whitesville, Raleigh-Boone Medical Center, 4th
Wednesday, 11 A. M.-l P. M. — May 25.
“Lower Gastro-Intestinal Disorders.” Warren
Point, M. D.
Williamson, Appalachian Power Auditorium, 1st
Thursday. 6:30-8:30 P. M. — May 5, “Update
Thyroid Dysfunction," Richard Kleinmann,
M. D.
Doctor Point ACP Governor
Dr. Warren Point of Charleston recently was
elected a Governor of the American College of
Physicians. Doctor Point, an internist and
Chairman of the Department of Medicine, West
Virginia University Medical Center, Charleston
Division, will hold his post as Governor of West
Virginia for four years.
A native of Charleston, he was graduated
from WVU, and received his M. D. degree in
1945 from Harvard Medical School.
Wildwater Medical-Surgical
Conference June 3-4
Colonic and breast cancer will be the subjects
of the day for the 10th annual Wildwater Con-
ference: Medical and Surgical Update, on
Saturday. June 4, in Charleston.
The meeting site will be the West Virginia
University Medical Center Education Building,
witjh the program to begin at 7:30 A. M. and
end at 3 P. M. Offered on Friday is a wildwater
trip on New River from Thurmond to Fayette
Station (15 miles).
Sponsors are WVU Charleston Division and
Charleston Area Medical Center.
The Saturday morning program on “The
Colonic Cancer Problem” will include five
speakers, who will join for a panel discussion
at the conclusion. The speakers and topics will
be “Chemotherapy-CA of the Colon” — Steven J.
Jubelirer, M. D., Assistant Professor of Medi-
cine, WVU Charleston Division; “Colonoscopy”
— Brittain Mcjunkin, M. D., Clinical Assistant
Professor of Medicine, WVU Charleston Di-
vision: “Radiological Diagnosis-CA of the
Colon” — Clinton A. Briley, M. D., Clinical As-
sistant Professor of Radiology, WVU Charleston
Division;
Boston. Wisconsin Speakers
“Surgical Treatment of CA of the Colon’ -
Claude Welch, M. D., Senior Surgeon, Massa-
chusetts General Hospital, Boston, and Clinical
Professor of Surgery, Emeritus, Harvard Medical
School; and “Polyps and Cancer" — Alvin L.
Watne, M. D., Professor and Chairman, WVU
Department of Surgery, Morgantown.
Speakers for the afternoon session, “Breast
Cancer in 1983,” will be William L. Donegan,
M. D., Professor of Surgery, University of
Wisconsin, on “New Approaches to Breast
Cancer;” Edward Wheatley. M. D., Clinical As-
sistant Professor of Radiology, WVU Charles-
ton Division, “Mammography in the Diagnosis
of CA of the Breast;” and Doctor Jubelirer,
“Chemotherapy-CA of the Breast.” A panel
discussion will follow.
The program is approved for five credit hours
in Category 1 of the Physician’s Recognition
Award of the American Medical Association.
Registration by May 27 is requested for the
scientific program. The fee, including lunch,
for physicians is $40 ($45 after May 27). For
additional information, telephone (304) 347-
1242.
The fee for the wildwater trip is $59. For
additional information or reservations, call ( 304 )
348-5511. Reservations are limited.
May, 1983, Vol. 79, No. 5
109
Keep Insanity Defense, Says
Doctor Bateman’s Group
The insanity defense in criminal trials should
not be abandoned, Dr. Mildred M. Bateman and
other members of a National Mental Health As-
sociation commission say in a report released
recently in Washington, D. C.
Doctor Bateman, Chairman of the Marshall
University School of Medicine Psychiatry De-
partment, said the group also opposes adoption
of the “guilty but mentally ill" verdict. (The
West Virginia Senate in its recently completed
session killed a bill which would have created
this verdict in the state.)
“One of the myths surrounding the insanity
defense is that it causes major problems for law
enforcement and the criminal justice system. '
Doctor Bateman said. “Actually, it’s successfully
used infrequently enough that it causes few
practical problems, but it does have a very
important moral role. We found that in a society
Review A Book
The following books have been received by the
Headquarters Office of the State Medical Associa-
tion. Medical readers interested in reviewing any
of these volumes should address their requests to
Editor, The West Virginia Medical Journal , Post
Office Bo\ 1031, Charleston 25324. We shall be
happy to send the books to you, and you may
keep them for your personal libraries after sub-
mitting to The Journal a review for publication.
Basic and Clinical Pharmacology , by Bertram
G. Katzung, M. D., Ph.D. 815 pages. Price
$23.50. Lange Medical Publications, Los Altos.
California 94022. 1982.
Living With Herpes, by Deborah P. Langston.
M. D. 198 pages. Price $7.95. Doubleday &
Company. Inc., 245 Park Avenue, New York.
New York 10167. 1983.
Current Medical Diagnosis and Treatment,
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Milton J. Chatton. M. D. 1130 pages. Price $24.
Lange Medical Publications, Los Altos, Cali-
fornia 94022. 1983.
General Ophthalmology, 10th Edition, by
Daniel Vaughan. M. D.; and Taylor Asbury,
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Publications, Los Altos, California 94022.
1983.
that has as its core a concern for the individual,
the plea is not only an appropriate part of the
criminal code, but a necessary one as well.”
She said that the “not guilty by reason of
insanity plea is used much less often than many
people believe. “Testimony before our commis-
sion indicated that of the 32.000 adult defend-
ants represented by the New Jersey public de-
fender last year, 52 entered insanity pleas —
and only 15 were successful,” she said. “In
Virginia, fewer than one per cent of the felony
cases involve the insanity defense.”
Disposition of Those Acquitted
The group also recommended that legislatures
adopt laws concerning the disposition of persons
acquitted under the insanity defense.
“We think that a lot of the public’s fear and
concern about the insanity defense is not so
much that a person can be acquitted because
he’s proven mentally ill, but what happens after-
ward." Doctor Bateman said. “Is he returned
to society as a free agent, or are there appropri-
ate custody and treatment programs available?
“The responsibility of the court does not end
with the Ending of not guilty by reason of in-
sanity." she said. “We recommend that the
states develop — and adequately fund
systems for providing treatment.”
She added that such programs reduce repeat
crimes. “Testimony we heard indicated that 76
per cent of patients released from Maryland’s
treatment and conditional release program were
not re-arrested in the four-year study period,”
she said.
The nine-member commission, led by former
U. S. Senator Birch Bayh. was formed to study
issues raised following the trial of presidential
assailant John Hinckley.
Group Elects MU Doctor
Dr. David K. Heydinger of the Marshall Uni-
versity School of Medicine was elected President-
Elect of the National Rural Primary Care As-
sociation at its recent annual meeting in Kansas
City.
He currently serves on the group’s board.
Doctor Heydinger, who joined the faculty in
1978. is Associate Dean for Academic Affairs
and Chairman of the Department of Family and
Community Health.
110
The West Virginia Medical Journal
Residency Locations Announced
For Marshall Graduates
Seventeen members of the Marshall University
School of Medicine’s 1983 graduating class of
36 students will remain in West Virginia for
their residencies, Dean Robert W. Coon, M. D.,
has announced.
Nine of the 17 will remain in Huntington, and
the others will go to Wheeling, Morgantown.
Clarksburg and Charleston, he said.
Remaining in Huntington are Frederick D.
Adams and Richard M. Hatfield, both of Logan:
Denise E. Clay Allen of Gilbert: Karen N.
Dansby of Ashland. Kentucky; Durwood F.
Gandee of Weirton; William D. Given of Strange
Creek: John L. Hahn of Wardensville; Darrell
W. Jordan of Ona, and Lou Gene Kingery of
Ken ova.
Other graduating seniors remaining in West
Virginia and their residency locations are:
David A. Brosius of Sutton and Kelly M.
Pitsenbarger of Franklin, United Hospital
Center, Clarksburg; Samuel R. Davis of
Marlinton and Wayne E. Groux of Wheeling.
Ohio Valley General, Wheeling:
Ronald DeAndrade, Jr., of Buckhannon. West
\ irginia University Hospital: Daniel B. Prudich
and Reginald J. McClung, both of Charleston,
and Mark K. Stephens of Madison, Charleston
Area Medical Center.
Other students and their residency locations
are: Gerald G. Blackwell of Gauley Bridge.
Ohio State University Hospitals; Leo R. Boggs,
Jr., of Danville, Hershey I Pennsylvania I Medi-
cal Center; Craig L. Bookout of Philippi, Self
Memorial Hospital. South Carolina: Mary B.
Butcher of Glenville, Riverside Methodist Hos-
pital. Ohio: James W. Endicott of Kermit, North
Carolina Baptist;
Albert J. Exner of Huntington, University of
Maryland; Bijan J. Goodarzi of Elkins, Akron
(Ohio I City Hospital: Garrie J. Haas of
Charleston, Ohio State University Hospital:
James D. Hoffman of Huntington, University
Health Center Hospitals, Pittsburgh; Harry J.
Magee of Charleston. University of California.
Los Angeles; Larry D. Mann of Princeton, Ohio
State University Hospitals;
Bradley R. Martin of Princeton, Akron City
Hospital; William E. Muth of Morgantown, Uni-
versity Hospitals, Madison, Wisconsin; Daniel
B. Ray of Ironton, Ohio. Aultman Timken Hos-
pitals, Ohio; Hobart K. Richey of Wellsburg,
University of Southern Florida-affiliated hos-
pitals;
William S. Sheils, Jr., of Huntington. Ohio
State l niversity Hospitals; Carol M. Spencer
of Huntington. Maine Medical Center; Sandra
L. Tabor of Switzer, Ohio State University
Hospitals, and Samuel D. Wellman of Kenova,
University of Louisville-affiliated hospitals.
Majority Of WVU Graduates
Choose Primary Care
Primary care specialties are the residency
choice of more than half the West Virginia Uni-
versity School of Medicine class of 1983.
Of the 80 seniors who will receive their M. D.
degrees on May 15. 46. or 57.5 per cent, will
take all or part of their postgraduate training
in either internal medicine, family practice or
pediatrics. Internal medicine is the choice of 22.
14 opted for family practice, and six chose
pediatrics.
Another three will combine pediatrics and
medicine residencies, and one will combine
medicine with psychiatry.
Exactly half of this year s class will remain
in West Virginia, including 21 at WVU, 16 at
the Charleston Area Medical Center (CAMC),
one at Ohio Valley Medical Center in Wheeling,
and two in Wheeling Hospital's Family Practice
Program.
Primary care areas also are the choice of
more than 67 per cent of those staying in the
state. Thirteen will enter family practice pro-
grams, 12 chose internal medicine, and two will
enter pediatric residencies.
Other residency choices among seniors are:
surgery, 12; emergency medicine, 5; ophthal-
mology and radiology, 4 each; psychiatry, 3;
anesthesia, 2, and obstetrics /gynecology, ortho-
pedics and pathology, one each.
One will enter a flexible residency program
and choose a specialty after the first year.
Class of ’83
Members of the class of 1983, their home-
towns and destinations are:
Arif A. Alidina, Lewdsburg, LTniversity of
Pittsburgh Health Center Hospitals; Robert D.
Allara, Iaeger, WVU Department of Ophthal-
mology; Michael T. Angotti, Clarksburg, Medi-
cal College of Virginia. Richmond: Harold G.
Ashcraft, Mannington, WVU Department of
May, 1983, Vol. 79, No. 5
111
Medicine: William C. Bird. Matoaka. WVU De-
partment of Pathology; Wayne R. Brearly,
Morgantown, Mercy Hospital, Pittsburgh; John
A. Burdette, St. Albans, CAMC: Kim B. Carey.
Weirton, WVU Department of Family Practice;
Janet E. Cogar. Flatwoods, University of Ken-
tucky Hospital, Lexington; Brad R. Cohen,
Charleston, CAMC;
Steven W. Collins, Glenville, North Carolina
Baptist Hospitals, Winston-Salem; Anne C.
Cutlip, Webster Springs, WVU Department of
Family Practice; William B. Dennison, Hunting-
ton, University of Kentucky Hospital, Lexington;
Mark T. Domenick, Morgantown, WVU Depart-
ment of Family Practice; Joseph D. Dye, Hunts-
ville, Alabama, Andrews Air Force Base Hos-
pital; Karen M. Fanucci, Morgantown, Mount
Auburn (Massachusetts) Hospital: Patrick R.
Felice, Morgantown. Saint Francis Hospital.
Connecticut; Linda S. Gray, Wheeling, Uni-
versity of Massachusetts Hospitals; Mark K.
Greathouse, New Manchester. Mercy Hospital.
Pittsburgh; Karen M. Gross. Martinsburg, WVU
Department of Family Practice;
Lynn H. Harris, Charleston. WVU Depart-
ment of Radiology: Jeffrey P. Hogg, Berkley.
University of Pittsburgh Health Center Hos-
pitals; Gavin N. Hogue, Scott Depot, CAMC:
Thomas L. Hurt, Morgantown, LTniversity of
California at San Diego; Richard J. Jackson.
Martinsburg, WVU Department of Surgery:
Jocelyn L. James, Morgantown. LIniversity of
Texas Health Science Center. San Antonio:
David T. Kirk, Scott Depot. Hunterdon Medical
Center, Flemington, New Jersey; Vincent P.
Kolanko, Weirton, WVU Departments of Medi-
cine and Pediatrics;
Susan L. Koletar, Pittsburgh, CAMC; Robert
W. Koss, Fairmont, WVU Department of Anes-
thesia; John S. Koval, Weirton, CAMC; Jane
A. Ku rucz, Morgantown, Ochsner Foundation
Hospital, New Orleans; Lester Labus, Barbours-
ville, and John A. Lane, Charleston, CAMC;
Robert A. Leadbetter, Morgantown, University
of Virginia Hospital, Charlottesville; Carolyn L.
I.ooney. Morgantown, Quillen-Disluin College of
Medicine, Johnson City, Tennessee; John A.
Mardones, Clarksburg, Rush-Presbyterian-St.
Luke s Medical Center, Chicago; David C.
Martin, Charleston, St. Louis University Hos-
pitals; Scott A. McNamara, Wheeling, George-
town University Hospital, Washington, D. C.:
Loren M. Meyer, Lutheran General Hospital,
Chicago; Aileen H. Miller, Chapel Hill, North
Carolina, Moses H. Cone Memorial Hospital.
( Continued on page xxiii )
New Patient Record Law
Effective In June
Here is the 1983 state legislative enactment,
proposed by the State Medical Association,
setting up provisions under which patients may
obtain copies of summaries of their records from
health care providers, including physicians. The
new act will be effective June 10.
“ARTICLE 29 I in Chapter 16 of the Code).
HEALTH CARE RECORDS.
Ҥ16-29-1. Copies of health care records
to be furnished to patients.
Any licensed, certified or registered health
care provider so licensed, certified or registered
under the laws of this state shall, upon the
written request of a patient, his authorized agent
or authorized representative within a reasonable
time, furnish a copy or summary of the patient’s
record to the patient, his authorized agent or
authorized representative subject to the follow-
ing exceptions:
( a ) In the case of a patient receiving treat-
ment for psychiatric or psychological problems,
a summary of the record shall be made available
to the patient, his authorized agent or authorized
representative following termination of the treat-
ment program.
( b ) Nothing in this article shall be construed
to require a health care provider responsible for
diagnosis, treatment or administering health care
services in the case of minors for birth control,
prenatal care, drug rehabilitation or related ser-
vices, or venereal disease according to any pro-
vision of the code, to release patient records of
such diagnosis, treatment or provision of health
care as aforesaid to a parent or guardian, without
prior written consent therefore from the patient,
nor shall anything in this article be construed to
apply to persons regulated under the provisions
of chapter eighteen ( education ) of this code or
the rules and regulations established thereunder.
I c I The furnishing of a copy or summary of
the reports of x-ray examinations, electrocardio-
grams and other diagnostic procedures shall be
deemed to comply with the provisions of this
article.
(dl For purposes of this article, “patient
record' does not include a provider's office
notes.
( e ) The provisions of this article may be
enforced by a patient, authorized agent or
authorized representative, and any health care
provider found to be in violation of this article
112
The West Virginia Medical Journal
shall pay any attorney fees and costs, including
court costs incurred in the course of such en-
forcement.
Ҥ16-29-2. Reasonable expenses to be
reimbursed.
The provider shall he reimbursed by the
person requesting in writing a copy of such
records at the time of delivery for all reasonable
expenses incurred in complying with this article.”
Council Action Embraces
Variety of Subjects
Concern regarding the potential impact of a
new state law setting up a hospital rate review
and rate setting mechanism was expressed by the
State Medical Association’s Executive Committee
and Council during April 9-10 meetings in
Charleston.
Major provisions of the 1983 enactment were
outlined in a Journal story in April, and Harry
Shannon, M. D., the Association’s President, has
devoted his monthly page to that issue this
month (seepage 104).
Council has instructed the Association staff
and legal counsel to monitor closely implementa-
tion of the new statute, to the extent of studying
the advisability of entering into any litigation
which might develop to test the law’s various
components.
In other action on April 10, the Council:
— Charged the Executive Committee and Com-
mittee on Professional Liability to meet with
representatives of CNA and McDonough Caper-
ton Shepherd to fashion a more comprehensive
loss control effort in line with the Association-
endorsed professional liability insurance pro-
gram.
Health Director Reports
— Heard State Health Director L. Clark
Hansbarger, M. D., report that each county
health department soon will have in hand ex-
tensive new statistical and other data that will
be used in planning future activity and working
with county commissions on budgets.
— Received a progress report on continued
planning toward a state headquarters building
in information provided by John Markey, M. D.,
in his role as President of West Virginia State
Medical Association Properties, Inc.
— Reviewed other 1983 legislative activity,
including enactment of a new statute relative to
patient records which is printed in its entirety
on page 112 of this issue of The Journal.
— Elected Carl J. Roncaglione, M. D.. to the
West Virginia Medical Political Action Com-
mittee ( WESPAC ) Board as the nucleus member
from the Third Congressional District to replace
Joseph T. Skaggs. M. D., who resigned.
Bylaws Amendments
— Approved for introduction in the Associa-
tion’s House of Delegates in August bylaws
amendments to make a Committee on Audit and
Budget a standing committee.
— Authorized introduction in the American
Medical Association House of Delegates in June,
in Chicago, resolutions to add state medical as-
sociation society presidents as members of the
House; and calling on the AMA to withdraw all
support from the Joint Commission on Accredita-
tion of Hospitals in view of proposed JCAH
standards revisions eliminating the term “medi-
cal staff" in lieu of an “organized staff. A draft
of the revisions also would, among other things,
eliminate references to physician responsibility
for the general condition of hospitalized patients;
and eliminate references to physician supervision
of treatment provided by limited licensed
practitioners.
—Voted to ask Thomas G. Potterfield. M. D.,
of Lewisburg to represent the Medical Associa-
tion on a School Health Advisory Council to
work with state education and health depart-
ments toward a comprehensive school health pro-
gram in West Virginia.
Honorary Memberships
— Elected to honorary membership, in the
wake of appropriate local society action, the
following: Drs. Eugene E. Hutton, Jr., Elkins;
Albert C. Esposito, Huntington; Edward Jackson,
St. Albans; Marion F. Jarrett, Charleston;
George R. Mullins, Logan; Charles S. Flynn,
Bluefield; Lawrence J. Pace, Princeton; Robert
T. Bandi and James C. Hazlett, both of
Wheeling; Robert M. Biddle, Little Hocking,
Ohio, and Jack J. Stark, Belpre, Ohio (both
Parkersburg Academy members ) ; and Grover
C. Hedrick, Jr., Paul E. Vaughan, Everett B.
Wray and John W. Whitlock, all of Beckley.
— Elected to retired membership Drs. J.
Dennis Kugel, Charleston; James L. Deadwyler,
Fairmont: and Andrew K. Butler, Herman Rubin,
William J. Steger and Robert 0. Strauch, all of
Wheeling.
May, 1983, Vol. 79, No. 5
113
Handicapped Newborn Rules
Challenged By AMA
The American Medical Association will file
an amicus brief in a suit challenging new regu-
lations in the treatment of severely handicapped
newborns. The friend-of-the-court brief will be
in support of a suit hied in March by the
American Academy of Pediatrics and the Na-
tional Association of Children's Hospitals.
The suit seeks to block enforcement of rules
requiring all hospital maternity wards, obstetri-
cal wards, and nurseries to post notices warning
that failure to feed and care for handicapped
infants is prohibited by law.
The notices encourage anyone who thinks an
infant is being denied food or “customary medi-
cal care” to call a hot line at the U. S. Depart-
ment of Health and Human Services, or to
telephone the state’s child protection agency.
“The purpose of a rule like this goes beyond
the decision between physicians and families
concerning a handicapped infant, ' said AMA
Executive Vice President James H. Sammons,
M. D. “Once a government agency has inter-
jected itself into the practice of one medical
specialty, that kind of interference could be ex-
panded to other specialties. Then each of us —
physicians and patients — would have our de-
cisions subjected to review by strangers making
arbitrary and perhaps capricious judgments
about our own life and death events, " he said.
The AMA will object to the unusually brief
public comment period before the rules went into
effect. The AMA also is opposed to a provision
that allows HHS investigators to have 24-hour
access to facilities if necessary to protect the life
or health of a handicapped infant.
The HHS rule was developed in response to
the death last year of a six-day-old boy afflicted
with Down’s syndrome. “Baby Doe died in
Bloomington, Indiana, after bis parents re-
quested that food and medical treatment be with-
held.
Doctor Traubert Appointed
Dr. John W. Traubert of Morgantown recently
was appointed to the Mead Johnson Awards
Committee of the American Academy of Family
Physicians. The committee was established to
administer an annual grant financing a year of
graduate training in an approved family practice
residency. Doctor Traubert is Professor and
Chairman, Department of Family Practice, West
Virginia University School of Medicine.
Medical Meetings
May 2-6 — Am. Psychiatric Assoc., New York City.
May 4-7 — WV Chapter, Am. College of Surgeons,
White Sulphur Springs.
May 6-8 — Southern Medical Assoc. Regional Post-
graduate Conference, Lexington, KY.
May 8-12 — Am. College of Obstetricians & Gyne-
cologists, Atlanta.
May 13-14— Topics in Cardiovascular Diseases (Am.
Heart Assoc.), Baltimore.
May 19-20 — National Conference, Breast Cancer
(Am. Cancer Society), Boston.
May 20-22 — Am. Counseling Assoc., Morgantown.
May 26-28 — Am. Assoc, of Genitourinary Surgeons,
White Sulphur Springs.
June 5-9 — Am. Society of Colon & Rectal Surgeons.
Boston.
June 7-10 — Society of Nuclear Medicine, St. Louis.
June 17-18 — Society for Vascular Surgery, San
Francisco.
June 19-23 — Annual Meeting of AMA House, Chi-
cago.
June 22-25 — Am. College of Surgeons, Eastsound,
WA.
June 23-26 — Am. Medical Women’s Assoc., Minne-
apolis.
Aug. 25-27 — 116th Annual Meeting, W. Va. State
Medical Assn., White Sulphur Springs.
Sept. 29-Oct. 2 — Am. Society of Internal Medicine,
San Francisco.
Oct. 16-21 — Am. College of Surgeons, Atlanta.
Oct. 22-27— Am. Academy of Pediatrics, San Fran-
cisco.
Oct. 23-27 — Am. College of Chest Physicians,
Chicago.
Oct. 23-29 — Am. College of Gastroenterology, Los
Angeles.
Nov. 6-9 — Scientific Assembly, Southern Medical
Assoc., Baltimore.
Nov. 30-Dec. 1 — Am. College of Chemosurgery,
Chicago.
114
The West Virginia Medical Journal
By now, car shoppers have resigned themselves to paying upwards of
$11, 000 for even an ordinary car.
This is unfortunate. Also unnecessary. Because for about the same money,
they could have an extraordinary car: the Saab 900.
The Saab 900 has everything the name would suggest and the price
wouldn’t, like jetronic fuel injection, a zero pollen air filter, 4-wheel disc brakes,
rack-and-pinion steering. As for front-wheel drive, we consider that so basic, we
don’t even bother to put it on the sticker.
Which brings up something else: While you could pay extra to get some of
Saab’s features on another car, you’d still have another car.
Or maybe Road & Track said it better. “Price is one of the things that makes
the 900 so attractive. The other is that it’s a Saab. ”
The most intelligent car ever built.
Harvey Shreve, Inc.
ROUTE 60, WEST ST. ALBANS 722-4900
WVU Medical Center
—News—
Compiled from material furnished by the Medical Center
News Service, Morgantown, W. Va.
ENT Laboratory Arm Of CDC
In AIDS Cause Quest
Acquired immune deficiency syndrome
(AIDS) is a modern medical mystery.
Scientists know that its greatest incidence is
among male homosexuals, Haitians and abusers
of intravenously injected drugs. The syndrome
also has affected some hemophiliacs, leading
researchers to believe its transmission may be
linked to blood products.
AIDS directly results from an imbalance in
subsets of certain white blood cells which brings
about a suppression of the immune response.
What changes this delicate balance? Is it
some bacterium, virus or combination of
pathogens? Or are many recurrent infections
from, or re-exposures to, some ever present,
disease-producing agent the answer?
As a regional laboratory for the Centers for
Disease Control ( CDC ) in Atlanta, WVU’s ENT
Diagnostic Laboratory is playing a part in
adding to the body of knowledge concerning this
phenomenon.
Virology and Immunology
The laboratory specializes in virology and
immunology. Its Director, James E. McClung,
M.S., took much of his graduate study at the
CDC with special emphasis on the Epstein-Barr
virus, one of the herpes family.
“CDC is interested in looking at the individual
with a slightly lowered cell-mediated immune
response who may be borderline for AIDS,”
McClung said. “In that way they hope to come
up with an etiological agent.”
“Probably the causative agent has come and
gone in the active AIDS cases who have
opportunistic infections or Kaposi’s sarcoma.”
Kaposi’s sarcoma, a rare type of skin cancer,
is found in 28 per cent of AIDS patients. Nearly
half of them fall victim to pneumocystis carinii
pneumonia, a protozoa infection.
But these diseases are believed to be the
results of impaired immunity, not its cause.
The instigator may be an ultravirus or a new
virus, McClung said.
“The current theory, however, is that AIDS
individuals have repeated bouts of infection with
cytomegalovirus, herpes simplex or possibly
Epstein-Barr, all members of the herpes family,”
he explained.
CMV Prime Suspect
“C.MV is probably the prime suspect right
now. Most individuals have very minor
symptoms with it. They get over it and have
no further problems. CMV causes a problem
with organ transplant patients and cancer
patients who are immunosuppressed.
“When the herpes viruses are active, the infec-
tion itself causes a suppression of the immune
response. It may be that AIDS victims have so
many recurrent infections or re-exposure to the
viruses that their immune systems just finally
break down.”
Hepatitis B, which also is found frequently
among homosexuals and drug users, and known
to be transmitted in blood products, also is
suspected as a contributing factor.
McClung said the diagnosis for AIDS was
made by the determination of the ratio of helper
T-cells to suppressor T-cells in a blood sample.
These white blood cells are involved in the
immune response — the helper cells fighting off
infection by aiding in the production of anti-
bodies, and the suppressor cells stopping the
response.
“In AIDS, the problem is a lower number of
helper cells but an increased number of suppres-
sor cells,” he said.
Foundation Appointment
Jack E. Riggs, M. D.. Assistant Professor of
Neurology, has been appointed to the medical
advisory hoard of the national Myesthenia Gravis
Foundation. Doctor Riggs is a medical graduate
of the University of Rochester, and joined the
WVU faculty in 1981.
xvi
The West Virginia Medical Journal
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Third-Party News, Views
and Program Concerns
Prospective Payment Approved,
‘Heavy Impact' Expected
Attached to the Social Security Act of 1983
recently approved by Congress and signed by
President Reagan are measures that will have
heavy impact on the nation’s health care system,
the American Medical Association has com-
mented. The bill contains provisions to hold
down the cost of Medicare payments to hospitals
through a prospective payment plan based on
diagnosis-related groups (DRGs). Hospitals will
be paid on the basis of 467 DRGs regardless of
the costs actually incurred in treating patients.
Under the bill approved by Congress:
— DRG payments will be phased in over three
years, beginning with the hospital’s first cost re-
porting period after October 1, 1983. In the first
year, 25 per cent of the payment will be based
on DRG rates, and 75 per cent on the hospital’s
cost base. The percentage of the payment based
on DRGs gradually will increase until it reaches
100 per cent in the fourth year.
— In the first year, the DRG portion of the
payment will be a regional rate. A rural and an
urban rate will be calculated for each of nine
regions. In the second and third years, the DRG
portion will be a blend of national and regional
rates and, by the fourth year, the 18 regional
rates will give way to two national rates — one
urban, one rural.
1984-85 Rates
-Rates in 1984 and 1985 will be adjusted by
the market-basket index of hospital costs plus
one per cent, but they would be reduced to the
extent this resulted in payments exceeding those
that would have applied under the Tax Equity
and Fiscal Responsibility Act targets.
—Beginning in 1986, the increase factor will
be determined by the Secretary of Health and
Human Services and reviewed by a 15-member
commission appointed by the Office of Tech-
nology Assessment. The commission is to include
representatives of a wide range of groups, in-
xviii
eluding new technology and treatments, and is to
recommend changes in the recalibration of the
DRG classifications.
Direct medical education expense will con-
tinue to be paid on a cost basis, and the current
Section 223 adjustment for indirect medical edu-
cation expenses will be doubled in the DRG
system.
Capital Costs
— Capital costs incurred before the system
took effect will continue to be reimbursed on a
reasonable cost basis until October 1. 1986. New
capital costs may or may not be paid on a rea-
sonable cost basis. States will be required to
have Section 1122 review systems, and Medicare
reimbursement for new capital costs will be con-
ditioned on 1122 approval. The maximum thres-
hold the state may use for requiring an 1122
review is increased from $100,000 to $600,000.
— Return on equity for proprietary hospitals
will be reduced.
— Certain types of institutions will be exempt
from the DRG system.
— From now until October 1, 1983, hospitals
are required to contract with a Professional Re-
view Organization I PRO I to monitor utilization
if there is a PRO in the area. After October 1.
the hospital is required to contract with a PRO.
and cannot be paid by Medicare if a PRO review
is not performed. Intermediaries will be allowed
to participate in the PRO program by October
1, 1984, at the latest.
Physician Charges Eyed
— State payment systems covering all payors
will be encouraged through waivers if the state
system will cost Medicare no more than the
federal DRG system.
-HHS is to report in 1985 on the ‘'advisabil-
ity and feasibility” of applying DRGs to physi-
cian charges for hospital services, and is to
recommend legislation to apply DRGs to physi-
cians.
The West Virginia Medical Journal
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Obit uaries
JAMES H. THORNBURY, M. D.
Dr. James H. Thornbury of Belle ( Kanawha
County ) died on March 19 in a Charleston
hospital. He was 74.
Doctor Thornbury was a retired physician for
the DuPont plant in Belle. He was Belle’s first
mayor.
Born in Genoa (Wayne County), he formerly
practiced in Man (Logan County | before going
to Belle 43 years ago. He was a former physician
for the University of Charleston.
Doctor Thornbury was graduated from West
Virginia University, and received his M. D. de-
gree in 1936 from Jefferson Medical College. He
interned at Newark (New Jersey) Memorial
Hospital.
Doctor Thornbury was a member of the
Kanawha Medical Society, West Virginia State
Medical Association and American Medical
Association.
Survivors include the widow; three sons,
James Thornbury of Webster. New York; Robert
Thornbury of St. Petersburg, Florida; and David
Thornbury of Lexington, Kentucky; a brother,
Lawrence Thornbury of Asbury I Greenbrier
County), and three sisters, Mrs. Frances Prochilo
of Massapequa. New York; Mrs. Nancy Cairoof
of Hampstead, New Hampshire, and Mrs.
Romaine Melara of Lewisburg.
# # #
THOMAS V. SHIELS, M. D.
Dr. Thomas V. Shiels of South Charleston
died on March 21 at his home there. He was 77.
Doctor Shiels, an internist, was a retired
physician for the Lfnion Carbide Corporation in
South Charleston.
Born in Craven. Saskatchewan. Canada, he
received both his undergraduate an d M. D.
(1939) degrees from the University of Illinois.
He interned at Swedish Covenant Hospital, and
took his residency at the Louisville Veterans
Administration Medical Center.
Doctor Shiels also had practiced for short
periods in Fayetteville. North Carolina, and
W illiamson.
Survivors include the widow; a stepson,
Paul Epperly of Ellenboro: a sister. Mrs.
Marjorie Thibodeau of \ ictoria, British Colum-
bia. Canada: and two brothers, Warren Shiels
of Standard. California, and Leonard Shiels of
Craven, Saskatchewan.
He was an honorary member of the Kanawha
Medical Society. West Virginia State Medical
Association and American Medical Association.
HIGHLAND HOSPITAL
56TH & NOYES AVE., S.E.
CHARLESTON, W. VA. 25304
925-4756
MEDICAL STAFF
ADULT PSYCHIATRY
Miroslav Kovacevich, M. D. 925-0693
Charles C. Weise, M. D. 925-2159
Thomas S. Knapp, M. D. 925-3554
Pablo M. Pauig, M. D. 343-8843
Ralph S. Smith, M. D. 925-0349
Lee L. Neilan, M. D. 925-0349
Edmund C. Settle, Jr., M. D. 925-6914
Gina Puzzuoli, M. D. 925-6914
John P. MacCallum, M. D. 925-6966
CHILD PSYCHIATRY
Henrietta L. Marquis, M. D.
Pablo M. Pauig, M. D.
Ralph S. Smith, M. D.
John P. MacCallum, M. D.
925-3160
343-8843
925-0349
925-6966
Psychiatric treatment for the emotionally
disturbed children ages 5 to 13 now avail-
able in new children's pavilion. Separation
maintained from adult psychiatric care
unit. Each program offers:
• Crisis Intervention
• Group Therapy
• Psychotherapy
• Activities & Recreational Therapies
• Skilled Attention to Family, Marital, and
Individual Emotional Problems
• Special Care for the Acutely Disturbed
Patient
• Staffed by Qualified Psychiatrists and
Medical Consultants
« Schooling Provided on Children’s Pa-
vilion
• Serving the Community for Over 25
Years
xx
The West Virginia Medical Journal
County Societies
FAYETTE
The Fayette County Medical Society met on
March 2 at Montgomery General Hospital.
The guest speaker was Dr. Kenneth M.
Harman of Charleston, whose topic was “Total
Parenteral Nutrition.” — S. S. Maducdoc, Jr.,
M. D., Secretary /Treasurer.
# #
JEFFERSON
Dr. Rebecca Garrett of Hagerstown. Maryland,
was the guest speaker for the meeting of the
Jefferson County Medical Society on March 2.
Her topic was “Arthritis.”
New officers were elected. — William S. Miller.
M. D., Secretary /Treasurer.
* * #
McDowell
The McDowell County Medical Society met
on March 9 in Welch at the Stevens Clinic Hos-
pital.
The guest speaker was Dr. Robert Lapin.
Clinical Assistant Professor of Medicine, In-
fectious Diseases. Albert Einstein Medical
College, New York City. His subject was
“Update on the Management of Medical and
Surgical Infections.” — Muthusami Kuppusami.
M. D., Acting Secretary.
Plant Medical Director
Physician is required to take charge of
established program in occupational medi-
cine. Previous experience or training in
occupational medicine is preferred. Com-
petitive starting salary and exceptional
benefits are available to a physician inter-
ested in residing in the Parkersburg, WV/
Marietta, OH area. Send CV to Box PAC,
c/o The West Virginia Medical Journal,
P. O. Box 1031, Charleston, WV 25324.
EQUIPMENT WANTED
WANTED TO BUY— Second hand office
and exam room equipment. Also, instru-
ments appropriate for Family Practice.
Send responses to Joseph I. Golden, M. D.,
P. O. Box 1645, Beckley, WV 25801.
WVU GRADS — Continued from page 112
Greensboro. North Carolina: Frederick E. Moore,
Charleston. Aultman Hospital. Canton. Ohio:
Larry W. Moreland, Mount Storm, WVU De-
partment of Medicine; Michael S. Solomon.
Parkersburg, CAMC; Alan L. Myers, Philippi.
W\ U Department of Behavioral Medicine and
Psychiatry: Patton V. Nickell. Buckhannon,
WVU Departments of Medicine and Behavioral
Medicine and Psychiatry: Ross S. Oliver.
V heeling. CAMC: Lawrence N. Payne, Parkers-
burg, Akron (Ohio) City Hospital; Debra G.
Perina, Harpers Ferry, Richland Memorial Hos-
pital. Columbia. South Carolina; Stuart W. Point,
Charleston. CAMC; Stephen R. Powell, Scott
Depot, WVU Department of Ophthalmology;
Lee A. Pyles. Fairmont, University of Minnesota
Hospitals; Janis E. Reed. Morgantown, St.
Francis General Hospital. Pittsburgh; Gary J.
Renaldo, Fairmont. Medical College of Virginia;
David M. Ritchie. Ravenswood, CAMC: Charles
L. Rolfe. Morgantown, Ohio Valley Medical
Center, Wheeling: William D. Rose, Geisinger
Medical Center. Charlton Heights. Pennsylvania:
David B. Rymer. Parkersburg, WVU Depart-
ment of Anesthesia; Ralph A. Sellers, Fairmont.
LIniversity of Mississippi Hospital: Henry L.
Setliff. Shady Spring. Lbiiversity of South
Florida Medical Center, Tampa: Robert N.
Shobe, Burlington. Allegheny General Hospital.
Pittsburgh; Sydney G. Short. Morgantown.
North Carolina Baptist Hospital: Cynthia C.
Sims. Colbers; William R. Sims. Huntington,
and Daniel L. Smith, Sissonville, CAMC:
Gregory D. Snodgrass, Gauley Bridge, and
Natalie C. Snodgrass, Wheeling. Ohio State Uni-
versity Hospitals; Thomas J. Soltis. Huntington.
WVU Department of Medicine; Jack R. Steel,
Morgantown, WVU Department of Orthopedics;
Phillip R. Stevens, Bridgeport, WVU Depart-
ment of Surgery;
Jane E. Thrush, Morgantown, LTniversity of
Pittsburgh Health Center Hospitals; Vincent C.
Traynelis, Morgantown. WVU Department of
Surgery; Michael B. Voorhees, Martinsburg,
W heeling Hospital; Charles B. Voss, Wheeling,
University of Hawaii Hospitals; James W.
Wallace, St. Albans, CAMC; Mark R. Weiser,
Parkersburg, Tripler Medical Center. Hawaii:
Daniel W. Wilson, St. Marys, Wheeling Hospital:
Cynthia A. Winger, Huntington, CAMC: Sanjay
S. Yadav, St. Albans. Veterans Administration
Medical Center, Long Beach, California; and
John M. Zambos, Beckley. WVLf Department of
Surgery.
May, 1983, Vol. 79, No. 5
xxiii
Professional
Liability Insurance
Designed for
West Virginia
Physicians
“The Association recommends
its endorsed program to you for...
your most considered review and
attention.”
Reprinted from The West Virginia Medical Journal, September 1981
Your Association’s Professional Liability Insurance Program Includes:
• A five-year market guarantee with Continental Casualty Company,
CNA, the fourth-largest underwriter of professional liability
insurance in the United States.
• A consent to settle provision for doctors covered under the plan.
• An in-state managing general agent, McDonough Caperton Shepherd
Group, with offices located in five key West Virginia cities
to provide risk management and technical expertise in professional
liability matters.
• A payment plan with no finance charges.
• A profit-sharing mechanism.
McDonough
Caperton
Shepherd
Group
Uniquely capable... Professionally competent
Corporate Headquarters: One Hillcrest Drive, East, P O Box 1551, Charleston, WV 25326 Telephone (304) 346-0611
With offices in; Beckley, Charleston, Fairmont, Parkersburg, Wheeling
The West Virginia Medical Journal /
Vol. 79, No. 6 June, 1983
Hospices Are Developing In West Virginia:
What Physicians Need To Know
PETER C. RAICH, M. D.
Professor of Medicine and Chief, Section of Hema-
tology Oncology, West Virginia University School of
Medicine, Morgantown
RICHARD JOHN C. PEARSON, M. B.. M.P.H.
Professor and Chairman , Department of Community
Medicine, WVU School of Medicine
RICHARD M. IAMMARINO, M. D.
Professor of Pathology and Director, Clinical Labora-
tories, WVU Medical Center; and President. Morgan-
town Hospice, Inc.
Hospice programs have grown rapidly within
the United States during the past decade. West
Virginia presently has five active hospice pro-
grams, and four in various stages of activation.
These programs are designed to provide care by
health professionals and volunteers to incurably
ill patients. Control of debilitating and demoral-
izing symptoms allows patients to remain within
their homes and family circle. Physicians can
contribute significantly to the care and under-
standing of such patients during the end stages
of their illness.
T Tospices came to be developed in response
to a perceived problem: the process of
dying was being mismanaged. Either too little
was being done for the patient because the
disease process ( usually cancer I was too far
advanced for treatment to be effective, and there
was a failure to appreciate that even when the
disease was incurable the patient still needed to
be cared for: or too much was done in a stub-
born. last-ditch, no-holds-barred battle against
the disease even when the prognosis was hopeless.
That the problem was real has become obvious
since approximately 600 hospices are active or
are being developed in the United States today.
This is all the more remarkable in that there
were none 12 years ago.
In West Virginia today there are five hospices
active: in Martinsburg, Wheeling, Charleston.
Huntington and Beckley; and there are four
more developing in Morgantown. Clarksburg,
Parkersburg and Putnam County (see Appen-
dix I .
History of Modern Hospice
While there is a long history of institutions,
usually church-related, where all kinds of sick
people have been lovingly cared for, the rapid
development of the hospice concept specifically
for the terminally ill in the United States in
recent years can be traced to two sources: tbe de-
velopment of a research and teaching hospice in
London. England, and the work of Dr. Elizabeth
Kubler-Ross. Dr. Cicely Saunders, in a London
hospital after the end of World War II, had
been nursing a dying man who was an exile
from his country and alone, and needed help
with a whole range of personal matters before
he could feel comfortable to die with his affairs
in order. They discussed the shortcomings of
the hospital services, and he left her funds to
establish a better way of caring for the terminally
ill. 1 She spent the next 20 years becoming pre-
pared to open her hospice to put into practice
their ideas, and act as a demonstration of what
could be done.
A year or two after this hospice opened,
Doctor Kubler-Ross’ book. On Death and Dying,
was published. 2 This book, which has become
June, 1983, Vol. 79, No. 6
115
a classic, deals with a series of interviews Doctor
Kubler-Ross carried out in a dying patient
population at the University of Chicago. In the
book, Doctor Kubler-Ross has characterized
what she calls the five stages of dying, namely,
“denial,” “anger,” “bargaining,” “depression.”
and “acceptance.”
Content of a Hospice Program
Hospice care does not relate to a place but a
concept of dealing with dying patients with
dignity, openness and compassion to help them
and their families reach “acceptance.” Although
hospice programs take many forms, the most
common one relates to a home care program
administered by the small nuclear staff which
coordinates services including skilled nursing
care, care by nurse’s aides, medical social
workers, ministers, and bereavement counseling
services following the death of the patient.
Hospice care is, of necessity, time-intensive.
It takes many people several hours to establish
a close relationship with the patients and their
families. For this reason, hospice programs have
had to rely heavily on trained volunteers for pro-
vision of many of the services where discrete,
medically defined skills were not necessary. The
characteristics of a hospice program are itemized
in Table l. 1 2 3 4 5 6 7 8 9 10
Recent Federal Legislation
Federal legislation was passed as a part of the
Tax Equity and Fiscal Responsibility Act, 1982,
that develops a mechanism for Medicare to pay
for hospice care. However, the regulations that
are being promulgated to implement this legisla-
tion in November, 1983, have features that will
TABLE 1
Characteristics of a Hospice Program of Care
1. Coordinated home care, with inpatient beds under a
central, autonomous hospice administration.
2. Control of symptoms (physical, sociological, psy-
chological, and spiritual).
3. Physician-directed services.
4. Provision of care by an interdisciplinary team.
5. Services available on a 24-hour-a-day, 7-day-a-week
basis with emphasis on availability of medical and
nursing skills.
6. Patient and family regarded as a unit of care.
7. Bereavement follow-up.
8. Use of volunteers as an integral part of the inter-
disciplinary team.
9. Structured personnel support and communication
systems.
10. Patients accepted to the program on the basis of
health needs, not ability to pay.
make it financially impossible for any hospice
in West Virginia, or in a rural area elsewhere
in the country, to be able to participate. The
regulations require the hospice: to provide
directly and substantially all of the nursing care
( hy an RN), the medical social services,
and physician and counseling (bereavement,
dietary and nutritional ) services; to retain super-
vision and management responsibility, including
central clinical records on all its patients; and to
be liable for hospital bills for patients who
incur bills greater than Medicare will pay.
None of the West Virginia programs has the
financial resources to handle these requirements.
Hospice programs in West Virginia will therefore
have to develop independently, and rely, at least
to some extent, upon volunteer services and
charitable contributions.
Do’s and Don’ts for Physicians
Following are some do’s and don’ts for
physicians:
1. Do get involved with the hospice move-
ment. If there is a hospice in your community,
see if there is any way that you can help.
2. Do refer patients for their care.
3. Don't be afraid that hospice personnel are
not professional. Typically, individuals who
work with a hospice are dedicated, and have had
training to fulfill their roles. These roles do not
replace physician services but amplify and
complement them.
4. Do be honest with your patients. If you
believe that they are terminal, then the message
needs to get across either to the patient or a
family member so that realistic family planning
can take place, and support from hospice can
be had.
5. Don’t withdraw just because you cannot
care or even palliate. You can still help with
symptom and pain control.
Symptom Control
Outlined below are two areas of symptom con-
trol.
I. Control of Pain in Cancer
Because of the diverse causes of cancer-
related pain, a number of treatment modalities
may be useful and worthy of consideration in
such patients (Table 2). Below we have selected
and discussed in greater detail some of the com-
monly used agents.
116
The West Virginia Medical Journal
TABLE 2
General Principles of Cancer Pain Management*
Cause of Pain
Primary Treatment
Secondary Treatment
To Consider
VISCERAL:
involvement of abdominal
or pelvic organs
Analgesics
Low-dose steroids
Celiac axis block for
abdominal pain. Intrathecal
block for pelvic pain
BONE PAIN:
Direct spread distant
metastases
1. Palliative radiotherapy
2. Non-steroidal, anti-
inflammatory drugs
3. Immobilization: Cervical
collar, pinning
Analgesics
Nerve block. Low-dose
steroids
SOFT TISSUE
INFILTRATION
Analgesics
Low-dose steroids
Nerve block
NERVE COMPRESSION
Analgesics
High-dose steroids
Nerve block
SECONDARY
INFECTION:
1. Systemic antibiotics
including metronidazole
if possibility of
anaerobes. Local surgery.
2. Systemic antibiotics.
Local applications, e.g.,
Providone, Iodine
Analgesics
Nerve block. Topical local
anesthetics
PLEURAL PAIN
Antibiotics if appropriate
Analgesics
Intercostal block
COLIC due to bowel
obstruction
Stool softeners.
Antispasmodics, e.g., Lomotil
Analgesics
LYMPHEDEMA
Intermittent positive pressure
machine
Analgesics.
Jobst sleeve or stocking
High-dose steroids
HEADACHES from raised
intracranial pressure
High-dose steroids. Raise
head of bed
Avoid opiate analgesics
Diuretics may help
PAIN in paralyzed
limb(s)
Physical therapy and regular
movement of limb(s)
Non-steroidal anti-
inflammatory drugs
Muscle relaxants
“Adapted from Ajemian I, Mount BM 6
A. Non-narcotic analgesics.
Aspirin and acetaminophen (Tylenol R ) are
the most commonly used. They are equal
in pain-relief activity. Both will decrease
fever, but aspirin is a stronger anti-inflam-
matory agent. Aspirin interferes with
platelet function and may lead to gastritis.
Pentazocine (Talwin R ) and codeine also
are active agents for moderate pain, and
potentiate the action of aspirin and
acetaminophen when combined with these
agents. However, pentazocine has bother-
some gastrointestinal and central nervous
system side-effects. Most of the newer
class of non-steroidal, anti-inflammatory
agents may be helpful in controlling
cancer-related pain, along with other
agents, especially in patients with metas-
tases to bone.
B. Narcotic Analgesics
Codeine is an effective oral agent for
moderate pain, and often is combined with
aspirin and acetaminophen, but may be
associated with constipation on prolonged
use. For more severe and chronic cancer-
related pain, more potent narcotic agents
are usually required. The oral administra-
tion of morphine sulfate has proven to be
especially valuable, and lends itself well
to home-care patients. 4 The oral-to-
parenteral potency ratio of morphine is
1:3. Although most patients’ pain is well
controlled on oral doses of 10-30 mg. every
four hours, in some patients as much as
100 mg. per dose may be required. Initial
drowsiness usually clears after the first
three to five days. Morphine sulfate may
be made up in simple solution or as a
flavored syrup. Morphine may be given
in combination with dextroamphetamine
five mg. with each morphine dose, except
at night, to reduce drowsiness. An anti-
emetic or oxyphencyclimine (Vistaril R )
for anxiety, or amitriptyline (Elavil R ) for
depression and sleeplessness also may be
added. Most hospice programs no longer
June, 1983, Vol. 79, No. 6
117
advocate the Brompton's cocktail type of
mixtures. Methadone is an alternate potent
oral narcotic analgesic and has the ad-
vantage of a longer drug half-life. The
usual dosage is five to 15 mg. every eight
to 12 hours. If nausea and vomiting pre-
clude oral analgesics, hydromorphone
hydrochloride ( I)ilaudid R ) suppositories
three mg. every four to six hours, are
useful.
C. Pain Control Without Drugs
These measures may help to control milder
pain, and when combined with analgesics
may be used while waiting for pain medi-
cations to take effect or during times of
incomplete pain relief. Distraction methods
include concentrating on slow, rhythmic
breathing and singing or tapping. Relaxa-
tion, imagery and skin stimulation with
massage, pressure, vibration or menthol
gels also may have an adjunctive role in
pain control.
II. Nausea and Vomiting
Nausea and vomiting can be a major problem
in cancer patients receiving cytotoxic chemo-
therapy or radiation therapy, hut also may be
secondary to the malignancy itself or its compli-
cations.’’ Control of these symptoms frequently
can he achieved with the proper selection and
trial of a variety of effective anti-nausea agents.
Th ese are usually available in oral, parenteral or
suppository preparations. The following have
been found to be especially useful in cancer
patients.
A. Phenothiazines — inhibit stimulation of
the chemo-receptor trigger zone.
Prochlorperazine (Compazine R ) five to
10 mg. q. four hours.
Chlorpromazine ( Thorazine R I 10 to 25
mg. q. four hours.
Triethylperazine (Torecan R ) 10 mg. tab.
or supp. q. four hours.
B. Antihistamines — diminish vestibular in-
put, mildly sedating.
Benadryl 25-50 mg. q.i.d.
C. Halperidol I Haldol 1, I one to two mg. q.
eight hours.
Metoclopramide I Reglan R ) — used IV for
cis-platinum-induced nausea.
D. Corticosteroids — may be combined with
effervescent phosphates.
Prednisone at one mg/kg. dose is treat-
ment of choice for hypercalcemia.
Dexamethasone I Decardron R ) for vomit-
ing secondary to raised intracranial pres-
sure four mg. q.i.d.
E. Tetrahydrocannabinol (THC) approved
for use only with chemotherapy at present.
F. Additional measures may be beneficial in
patients with troublesome nausea and
vomiting:
1. Identify and eliminate cause where
possible.
2. Vomiting is often tolerated in the
the absence of nausea.
3. Frequent oral hygiene, especially after
each emesis and prior to meals.
4. Eliminate repulsive odors and sights.
5. Bowel regulation.
6. Frequent small bland feedings when
desired, including carbonated bever-
ages.
7. Antiemetics one hour before meals.
By the judicious use of these and other
methods of symptom control the quality of life
may be improved dramatically in such patients.
Much can be done to help patients and their
families during the terminal phase of illness. The
hospice program merely allows for the proper
blending of the skills of health professionals with
the dedication of volunteers.
‘‘Surely though the recovery of the patient
be the grand aim of their I physicians’ ) pro-
fession, yet where that cannot be attained,
they should try to disarm death of some of
its terrors, and if they cannot make him quit
his prey, and the life must be lost, they may
still prevail to have it taken away in the
most merciful manner. '
William Heberden, 1710-1801
Editors Note: Here are the generic drugs
and trade names (in parentheses) to which
reference is made in this manuscript : aceta-
minophen I Tylenol); aspirin ; amitriptyline
hydrochloride {Elavil); chlorpromazine (Thora-
zine); codeine sulfate; dexamethasone I Decad-
ron ) ; dextroamphetamine ( Obetrol ) ; diphen-
hydramine hydrochloride (Benadryl); halo-
peridol (Haldol); hydromorphine hydrochloride
I Dilaudid); metoclopramide (Reglan); mor-
phine sulfate; oxyphencyclimine (Vistaril) ; pen-
tazocine ( Talivin ); prednisone; prochlorperazine
( Compazine | ; tetrahydrocannabinol; and trie-
thylperazine ( T ore can ) .
118
The West Virginia Medical Journal
References
1. Stoddard S: The Hospice Movement, New York,
Stein and Day, 1978.
2. Kubler-Ross E: On Death And Dying, New York.
MacMillen, 1969.
3. Lack SA, Buckingham III, RW: First American
Hospice, New Haven, CT, Hospice, Inc, 1978.
4. The Clinical Cancer Letter, 1982; 5(2):6-8.
5. Seigel LJ, Longo DL: The control of chemo-
therapy-induced emesis. Ann Int Med 1981; 95(3):352-
359.
6. Ajemian I, Mount BM (eds): The Roijal Victoria
Hospital Manual on Palliative/ Hospice Care : A Resource
Book, New York, Arno Press, 1980.
Appendix
Contact Persons for Hospices in West Virginia
Hospice of Martinsburg, Inc.
Mr. Larry Crawley-Woods
Rt. 1, Box 211
Martinsburg 25401 229-8886
Clara Welty Hospice
Mr. Larry Papi, Executive Director
109 Main Street
Wheeling 26003 232-3370
Kanawha Hospice Care Inc.
Ms. Beckv Bailey, R.N., Program Director
P. O. Box 2013
Charleston 25327 343-9843
Hospice of Huntington, Inc.
Mrs. Laura Darby, Volunteer Coordinator
1600 S. Jefferson Drive
Huntington 25701 429-1972
Raleigh County Hospice Care
Darrell Moore
Box 1571
Recklep 25801
Morgantown Hospice, Inc.
Marge Kearney, Executive Director
1000 Van Voorhis Road
Morgantown 26505 598-3424
Hospice Association of Greater Parkersburg Area
Mrs. Linda Dye, President
Dudley Avenue
Parkersburg 26101
People’s Hospice, Inc.
Del Parrish, President
United Health Center
Box 1680
Clarksburg 26301
Hospice of Putnam County'
Ms. Robin Rogers, Secretary
Rt. 3, Box 308-A
Hurricane 25526
Lewisburg Area Hospice Interest Croup
Ms. Frances Doss, R.N.
Denmar Hospital
Hillsboro 24946 653-4201
485-8216
624-2265
562-2646
Teens’ Newborns Not Always Less Healthy
A lthough teenage pregnancy is considered a major social problem in the United
States, the newborns of teenage mothers are not necessarily less healthy than those
of older mothers, according to two University of Michigan researchers.
Newborns and infants of teenage mothers, although often weighing less than offspring
of mothers in their 20s, actually score higher on some tests of early physical and mental
development, write Stanley M. Garn, Ph D., and Audrey S. Petzold, from the Uni-
versity’s Center for Human Growth and Development, in a recent issue of American
Journal of Diseases of Children.
June. 1983, Vol. 79, No. 6
119
Surgical Treatment Of The Subclavian 'Steal' Syndrome
ALI F. ABURAHMA, M. D.
Clinical Associate Professor in Surgery and Director,
Noninvasive Vascular Laboratory, West Virginia Uni-
versity Medical Center, Charleston Division
WILLIAM E. LAWTON, JR., M. D.
Clinical Associate Professor in Surgery, WVU Medical
Center, Charleston Division
Various procedures have been proposed for
the treatment of subclavian “steal” syndrome,
none of which has been uniformly accepted by
vascular surgeons. The authors analyze their
experiences with this problem with emphasis on
axillary-to-axillary bypass for the surgical cor-
rection of this disease.
/^\F the patients with symptomatic subclavian
“steal’’ syndrome who were corrected
surgically at Charleston Area Medical Center
between August, 1978, and February, 1982, 20
were corrected either by axillary-to-axillary
artery bypass I 12 patients) or carotid-to-
subclavian bypass (eight patients). All other
cases were excluded.
Ten of the 12 axillary-to-axillary bypass grafts
and two of the carotid-subclavian bypasses ( 12
of 20 cases ) were done by our group.
Figure la. A patient with complete occlusion of
the left subclavian artery.
Analysis of 12 Patients
Ages range from 44 to 66 years. There were
five males and seven females.
Ten of our 12 patients had clinical symptoms
of left subclavian “steal’’ (Figure 1). Tw'o of
these had left arm claudication. Of the remain-
ing two, one had right subclavian “steal” and
the other had both right subclavian “steal” and
right carotid “steal” secondary to innominate
artery occlusion (Figure 2). All of these patients
had an arm Doppler pressure difference of >
15 mm. Hg and a weaker pulse on the diseased
side. All patients are analyzed in the Table.
Follow-up period ranged from three to 40
months.
Axillarv-to-Axillary Technique
Two transverse incisions are made over the
delto-pectoral grooves. The incision is deepened
to expose the axillary artery, axillary vein and
brachial plexus. The second portion of the
axillary artery is isolated. An eight-mm Cortex
graft is sutured in place in end-to-side fashion.
The graft is placed underneath the pectoralis
major and then through a tunnel which is made
Figure lb. The same patient with left subclavian
“steal.”
120
The West Virginia Medical Journal
in the presternal subcutaneous tissue to the The distal end of the graft is then sutured to the
contralateral axilla. The contralateral end of the other axillary artery in end-to-side fashion
graft also is placed under the pectoralis major. (Figures 3a and 3b 1.
TABLE
Twelve Patients with Subclavian “Steal” Syndrome
Case
Age
Sex
Radiological
Findings
Operation
Followup
in months
Complications
Patency
1
62
M
Left subclavian stenosis
with vertebral “steal”
Axillary-axillary
bypass
24
None
Patent
2
64
F
”
”
23
”
tt
3
50
F
Left carotid
subclavian bypass
26
tt
4
56
F
Axillary-axillary
bypass
40
tt
5
54
M
”
28
”
6
44
F
Left carotid
subclavian bypass
32
rt
7
62
M
Rt. subclavian stenosis
with vertebral “steal”
Axillary-axillary
bypass
27
Parasthesia of hand-
one week
tt
8
66
M
Left subclavian stenosis
with vertebral “steal”
21
None
tt
9
59
F
Left subclavian stenosis
with vertebral “steal”
Axillary-axillary
bypass
18
tt
10
63
F
”
”
12
”
11
53
M
Innominate occlusion
with right carotid and
subclavian “steal”
3
Thrombosis &
infection
Removed
12
63
F
Left subclavian stenosis
with vertebral “steal”
5
None
Patent
Figure 2a. A patient with complete occlusion of Figure 2b. The same patient with right carotid
the innominate artery which showed right sub- “steal.”
clavian “steal.”
June, 1983, Vol. 79, No. 6
121
Carotid-to-Subclavian Bypass
A transverse supraclavicular incision is made.
The subcutaneous tissue, platysma and clavicular
head of the sternocleidomastoid muscle are
incised. The sternal head of sternocleidomastoid
is retracted medially and the common carotid
artery exposed and isolated. The scalenus anti-
cus muscle is transected after isolation of the
phrenic nerve. The subclavian artery is exposed
and isolated. The graft is sutured to the sub-
clavian artery in end-to-side fashion. The distal
end of the graft is then anastomosed to the side
of the common carotid artery (end to side)
I Figure 4 ) .
Results
The results are summarized in the Table. All
symptoms of subclavian “steal” and arm
ischemia disappeared. The blood pressure be-
came equal in both arms, and normal pulses were
restored. There have been no complications in
the two carotid subclavian bypasses ( 26 and 32
months ) . One patient who had axillary-to-
axillarv bypass had thrombosis of the graft three
days after surgery. Thromboembolectomy was
done but two months later infection necessitated
removal of the graft. This case was an emergency
axillary-to-axillary bypass for acute occlusion of
the innominate artery with right subclavian and
carotid “steal” with acute ischemia of the right
Figures 3a (top) and 3b (bottom). Axillary-to-
axillary artery bypass graft.
arm. All other cases (90 per cent) are still
patent. Patency rate was determined during
five to 40 months' followup. There was no
mortality in our series.
Discussion
This interesting syndrome was first described
by the Italian radiologist, Contorni. 1 in 1960.
Pieivieh et air presented the first two cases in
American Literature in the New England Journal
of Medicine (Editorial) A In this situation the
proximal subclavian artery, usually the left, is
occluded while the ipsilateral vertebral artery is
patent. There is reversal of flow in the vertebral
artery with blood flowing from the brain into the
arm distal to the subclavian occlusion via the
patent vertebral vessel.
With loss of blood from the brain stem and
cerebellum, one may have manifestations of
vertebrobasilar insufficiency, e.g., vertigo, head-
ache. bilateral visual disturbances, dysarthria,
dysphagia, disorders of equilibrium, impairment
of consciousness and drop attacks. There may
be monoparesis or paralysis shifting from side
to side and involving any or all of the extremities.
Sensory defects on both sides of the body,
cranial nerve paralysis, and cerebellar signs with
ataxia also occur. These symptoms may be
precipitated by exercise of the ipsilateral arm.
Detailed serial arteriograms are necessary to
establish the diagnosis of this syndrome. Unless
symptomatic, patients with this syndrome need
not be subjected to surgical correction.
Figure 4. Carotid-to-subclavian bypass graft.
122
The West Virginia Medical Journal
Current Surgical Modalities
Technical procedures have changed consider-
ably during the past decade. In the past, stenoses
of the innominate and subclavian arteries were
treated by direct endarterectomy or with bypass
graft taking origin from the arch of the aorta.
Although blood flow restoration was quite satis-
factory, it soon became obvious that mortality
and morbidity for these procedures were quite
high ( 20-per cent mortality 1 . 4
Consequently, new methods were devised for
treating these lesions, resulting in the use of
extrathoracic approaches and cervical bypass
procedures almost routinely. These operations
are simpler to perform, carry a low mortality
and morbidity, and are quite satisfactory.
1. Carotid-to-Subclavian Bypass: Its technique
was described earlier (Figure 4). This pro-
cedure was described first by North’ and associ-
ates, and popularized by Diethrich. 6
Advantages:
A. Extrathoracic approach - — much less
morbidity and mortality.
B. The long-term patency rate is excellent.
Diethrich et al. reported 125 patients with
carotid subclavian bypasses followed from nine
months to 14 years with a 4.8 mortality. Only
two grafts failed ( one thrombosis and one in-
fection ).
Disadvantages:
A. Possible vascular “steal” from the ipsi-
lateral carotid artery. ,8 However, this point has
been controversial; supporters of the procedure
have pointed out both clinically and experi-
mentally that there would be no “steal with this
kind of procedure. 5,6
B. The necessity of clamping the donor carotid
artery while the proximal anastomosis is being
performed.
C. Possible cerebral embolization from the
graft suture line.
D. Stenosis of the carotid graft by kinking
with neck motion.
E. Rarely, injury to phrenic nerve or thoracic
duct.
F. The subclavian artery is usually a friable,
thin-walled vessel, and may present technical
difficulty in graft anastomosis. Blaisdell 9 re-
ported a four-per cent incidence of central
nervous system complications after carotid sub-
clavian bypass.
There was a total of eight cases of carotid
subclavian bypass done at Charleston Area Medi-
cal Center in the last three years. All these are
still patent.
2. Axillary-to- Axillary Artery Bypass: In
1971, Myers et aid 0 first reported the use of the
axillo-axillary bypass in revascularizing an upper
extremity in a very-poor-risk patient. Since
then, the reported experiences ( not including our
12 I total 38 cases:
Source
Year
Cases
Myers et aid 0
1971
2
Mozersky et aid 1
1972
3
Jacobson et aid 2
1973
1
Dardik & Dardik 1
8 1974
2
Leveen et ald A
1974
1
Snider et ald J
1974
6
Lamis et aid 6
1976
9
Myers et aid
1979
14
AbuRahma et al.
Present Series
12*
"These cases were done to both good- and
high-risk patients.
The results of all the reported experiences
have been excellent with good restoration of
antegrade flow in the recipient vessels and with-
out evidence of a “steal from the donor vessel.
Advantages:
A. Extrathoracic.
B. Simple.
C. Does not require carotid manipulation.
D. Does not require subclavian dissection
( i.e.. will avoid injury to phrenic nerve, thoracic
duct, etc.)
E. Easy to palpate and follow.
Disadvantages:
A. Possible compression of the graft against
the sternum; this is very rare.
B. Needs careful dissection of the axillary
artery to avoid injury to the brachial plexus.
( That is why we select the second portion of the
axillary artery as the donor site.)
A total of 12 cases were treated at Charleston
Area Medical Center, 10 of these by our group.
There was no mortality or morbidity except in
one case where thrombosis and infection
occurred I three to 40 months’ followup).
Subclavian artery transposition or implanta-
tion into the common carotid artery could be
done instead of the carotid-to-subclavian bypass.
June, 1983, Vol. 79, No. 6
123
Figure 5. Case of complete occlusion of left subclavian artery which was corrected by subclavian artery
transposition or implantation into the common carotid artery.
The only difference here is that instead of using
a graft, the distal end of the subclavian distal to
the occlusion is anastomosed to the common
carotid artery (Figure 5). It has the same ad-
vantages and disadvantages of carotid subclavian
bypass.
Subclavian-to-subclavian artery bypass also
can be done. In this procedure, both subclavian
arteries are exposed, as described previously, by
supraclavicular incisions (Figure 6). This pro-
cedure was described briefly by Blaisdell el al. 9
and Fhrenfeld et al . 18 in 1968 and 1969.
Finkelstein et al. 19 reported the first 15 patients
who had this procedure in 1972. He reported
no mortality or morbidity in all 15 patients who
were followed from six months to four years.
Summary
Various procedures have been proposed for
the correction of symptomatic subclavian “steal”
Figure 6. Subclavian-to-subclavian artery bypass.
syndrome. Twenty cases of these were treated at
Charleston Area Medical Center in the last four
years: 12 with axillary-to-axillary artery bypass,
and eight with carotid subclavian bypass. There
was no mortality. One patient had thrombosis
and infection of the graft, while the remaining
19 had patent grafts (three to 40 months’ follow-
up). All patients’ symptoms and signs were
relieved.
Axillary-to-axillary bypass currently is our
procedure of choice for the correction of
symptomatic subclavian “steal” syndrome. It
appears to be the simplest to perform with the
least potential complications.
References
1. Contorni L: The vertebro-vertebral collateral cir-
culation in obliteration of the subclavian artery at its
origin. Minerva Chir 1960; 15:268.
2. Reivich M, Holling HE, Roberts B. Toole JF: Re-
versal of blood flow through the vertebral artery and its
effect on cerebral circulation. N Engl ] Med 1961;
265:878.
•3. Editorial: A new vascular syndrome— The sub-
clavian “steal.” N Engl ] Med 1961; 265:912.
4. Crawford ES. DeBakey ME, Morris GC Jr, Howell
JF: Surgical treatment of occlusion of the innominate,
common carotid and subclavian arteries. A 10-vear ex-
perience. Surgery 1969; 65-17.
5. North RR, Fields WS, DeBakey ME, Crawford ES:
Brachial-basilar insufficiency svndrome. Neurology 1962;
12:810.
6. Diethrieh EB, Garrett HE, Ameriso J et al.: Oc-
clusive disease of common carotid and subclavian arteries
treated bv carotid-subclavian bypass. Am J Surg 1967;
114:800-808.
7. Dumanian AV, Frahm CJ, Pascale LR et al.: The
surgical treatment of the subclavian “steal” syndrome.
/ Thorac C.ardiovasc Surg 1965; 50:22.
124
The West Virginia Medical Journal
8. Harper JA, Golding AL, Mazzli EA, Cannon JA:
An experimental hemodynamic study of the subclavian
“steal” syndrome. Surg Gynecol Obstet 1967; 124:1212.
9. Blaisdell WV, Clauss RH, Galbraith JG et ah:
Joint study of extracranial occlusion. IV. A review of
surgical complications. JAMA 1969; 209-1889.
10. Myers WO, Lawton BR, Sautter RD: Axillo-
axillary bypass graft. JAMA 1971; 218:826.
11. Mozersky DJ, Sumner DS, Barnes RW et al.: The
hemodynamics of the axillo-axillarv bypass. Surg Gynecol
Obstet 1972; 135:925-929.
12. Jacobson JH, Mozersky DJ, Mitty HA et ah:
Axillary-axillary bypass for the “subclavian steal” syn-
drome. Arch Surg 1973; 106:24-27.
13. Dardik H. Dardik I : Axillo-axillary bypass with
cephalic vein for correction of subclavian “steal” syn-
drome. Surgery 1974; 76:413-418.
14. LeVeen HH, Piccone VA Jr, Diaz C et al.: A
simplified correction of subclavian “steal” syndrome.
Surgery 1974; 75:299-304.
15. Snider RL, Porter JM, Eidemiller LR: Axillary-
axillary artery bypass for correction of subclavian artery
occlusive disease. Ann Surg 1974; 180:888.
16. Lamis PA, Stanton PE, Hyland L: The axillo-
axillary bypass graft. Arch Surg 1976; 111:1353.
17. Myers WO, Lawton BR, Jefferson FR et ah:
Axillo-axillary bypass for subclavian “steal” svndrome.
Arch Surg 1974; 114:394.
18. Ehrenfeld WK, Levin SM, Wylie EJ: Venous
crossover bypass grafts for arterial insufficiency. Ann
Surg 1968; 167:287.
19. Finkelstein NM, Byer A. Rush BR: Subclavian-
subclavian bypass for the subclavian “steal” svndrome.
Surgery 1972; 71:142.
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June, 1983, Vol. 79, No. 6
125
From the West Virginia University
Medical Center
Edited By
Angel V asquez, M. D.
Professor of Pediatrics
and
Irma H. Ullrich , M. D.
Associate Professor of Medicine
Ketotic Hypoglycemia
Discussant:
JOSEPH P. CATLETT
Medical Student III
Although its etiology is still unknown, ketotic
hypoglycemia remains the most common cause of
childhood hypoglycemia, representing 65 per
cent of the cases. This disorder affects children
predominantly between the ages of one and 1.5
years, and remits spontaneously with increasing
age, usually before eight or nine. These children
are symptom-free between episodes.
Clinically, one should suspect ketotic hypo-
glycemia in any child older than one year with
central nervous system symptoms, decreased
blood sugar, and ketonuria in the absence of
hepatomegaly. Ketotic hypoglycemia can be
distinguished from hyperinsulinism with a glu-
cagon challenge test performed after provocation
of symptomatic hypoglycemia by fasting or ad-
ministration of a high-fat, ketogenic diet.
Treatment is relatively simple: administration
of a high-carbohydrate, high-protein diet with
extra feeds at bedtime, in conjunction with an
early breakfast. This usually precludes the need
for drug therapy. F or acute hypoglycemic epi-
sodes, oral or intravenous glucose is quite effec-
tive.
Long-term prognosis is good. The risk of
mental retardation and intelligence impairment
is proportional to the degree of control and
frequency of hypoglycemic episodes.
A lthough its etiology is still unknown, ketotic
hypoglycemia remains the most common
cause of childhood hypoglycemia, accounting for
65 per cent of the cases. This disorder affects
predominantly children between the ages of one
and 1.5 years, and remits spontaneously with
increasing age, usually before eight or nine.
These children are symptom-free between hypo-
glycemic episodes.
History
Ross and Joseph first noted the combination of
convulsions, hypoglycemia and ketonuria in
1924. In 1964, Colle and Ulstrom performed a
classic study on childhood hypoglycemia, and are
quoted extensively throughout the subsequent
and current literature. They studied children
with recurrent episodes of symptomatic hypo-
glycemia associated with ketonuria which oc-
curred after a period of low carbohydrate intake.
The hypoglycemia exhibited a minimal or no
response to glucagon.
Clinical Picture
Clinically, a previously active, healthy child
gradually develops lethargy, somnolence, hypo-
tonia and, in extreme cases, coma and seizures
after a period of fasting or low carbohydrate in-
take. Vomiting is usually associated with hypo-
glycemia. Blood glucose is usually 50 mg/dl,
and can be as low as 18-20 mg/dl. The symptoms
respond dramatically to oral glucose or, if the
patient is unresponsive, to intravenous glucose.
126
The West Virginia Medical Journal
These children generally have a history of being
small-for-gestational-age infants, and of prema-
turity. Physical examination is significant for
the absence of hepatomegaly.
In summary, the Colle and Ulstrom study il-
lustrated the following characteristics of the dis-
order. 1
1 ) The patients appear to be in good health
prior to attacks.
2 ) The first attack rarely occurs before the
age of 18 months.
3 ) Attacks occur after a period of food de-
privation.
4) Ketonuria is associated with the hypogly-
cemia.
5 ) Response to glucose is prompt.
6 ) Fasting hlood glucose levels are normal be-
tween attacks. There is no hypoglycemia after
glucose loading. When the patient receives a
normal diet, glycogen stores are present after a
12-hour fast, and are discharged in response to
glucagon and/or epinephrine.
7 ) Most children are normal or near normal in
intelligence; attacks tend to decrease in fre-
quency as they become older.
8) The children are below the fifteenth per-
centile in both height and weight but are more
retarded in weight than in height.
Differential Diagnosis
The differential diagnosis of childhood hypo-
glycemia involves a number of complex disorders
which can usually be ruled out by history, physi-
cal examination and laboratory data. Explaining
each of these cases is beyond the scope of this
paper and can be found in any good pediatric
text. A basically complete list follows: 5,6
A. Hyperinsulinemia — ruled out by negative
response
to intramuscular glucagon
1)
Beta cell hyperplasia
2)
Islet cell adenoma or adenocarcinoma
3)
Nesidioblastosis (hyperplasia of the
cells of Islets of Langerhans)
4)
Extra-pancreatic tumors
5 )
Beckwith-Wiedemann syndrome 1 mac-
roglossia. macrocephaly, hepatomegaly,
somatic giantism, omphalocele)
6l
Prediabetes
7)
Leucine sensitivity
8)
Maple syrup urine disease
9)
Idiopathic
B. Substrate limited
1 ) Ketotic hypoglycemia — represents 65
per cent of all childhood hypoglycemia,
characterized by hypoglycemia with
ketonuria, glucagon resistance, and
small-for-gestational-age infants
2 ) Glucagon deficiency
3) Primary liver disease
4) Catecholamine insufficiency (Zetter-
stron syndrome)
5 ) Endocrine deficiencies ( growth hor-
mone, cortisol, etc.)
C. Enzyme defects
1 ) Glycogen storage disease — hepato-
megaly and growth failure
a. Glucose - 6 - phosphatase
b. Amylo - 1.6 - glucosidase
c. Defects of the phosphorylase cascade
system
2 ) Cluconeogenetic enzyme defects —
Fructose - 1.6 - diphosphatase
3 ) Other enzymatic defects
a. Glycogen synthetase — clinical pic-
ture similar to ketotic hypoglycemia
b. Galactose - 1 phosphatase
c. Fructose - 1 phosphate aldolase.
D. Due to drugs and toxins
1 ) Ethyl alcohol
2 I Salic vlates and Tylenol f1T)
3 I Sulfonylureas
4 ) Propranolol
5 I Jamaican vomiting sickness
E. Other
1 ) Hepatic damage
a. Reye’s syndrome
b. Leukemia
2 ) Malabsorption
3 I Renal glycosuria
4 ) Malnutrition
a. Kwashiorkor
b. Low phenylalanine diet
These diagnoses can be excluded by history,
examination and laboratory studies. Ketotic
hypoglycemia, hyperinsulinism and glycogen
synthetase deficiency present similar pictures and
have to be differentiated. In order to distinguish
ketotic hypoglycemia from hyperinsulinism, the
diagnosis is confirmed by provoking symptomatic
hypoglycemia with fasting or by administration
June, 1983, Vol. 79, No. 6
127
of a high-fat, ketogenic diet. 4 A glucagon chal-
lenge test is then performed. 3 This involves a
24-hour fast with prior baseline blood glucose
and insulin levels determined. Subsequently,
blood glucose and urine ketones (by Acetest) are
determined at four-hour intervals. When the
blood glucose level falls to 50 mg/ dl ( usually 12-
24 hours later), glucose and insulin levels are
drawn. Usually, in ketotic hypoglycemia, keto-
nuria develops after less than 6-8 hours of fast-
ing. followed by the appearance of symptomatic
hypoglycemia between 12-24 hours. The fast is
ended with a one-mg intramuscular injection of
glucagon, and blood glucose levels are obtained
at five, 10 and 15 minutes after injection. Hypo-
glycemia that does not respond to glucagon is
virtually diagnostic of ketotic hypoglycemia. In-
sulin levels are within normal limits (normal
fasting insulin levels 10-30 IU/ml).
Note that the clinical picture of glycogen syn-
thetase deficiency is similar to that of ketotic
hypoglycemia, and also has a minimal response
to glucagon. 3 Assay of hepatic glycogen syn-
thetase can be used to differentiate, but among
patients labeled ketotic hypoglycemia, persistent
hyperglycemia and increase in serum lactate con-
centration after administration of glucose should
reveal those with possible deficiencies of glycogen
synthetase. This latter disorder, however, is ex-
tremely rare.
Etiology and Pathogenesis
Failure to decrease glucose utilization in re-
sponse to fasting or a ketogenic diet appears to
be the main cause of hypoglycemia in these
children. The disorder remits spontaneously with
increasing age. usually before eight to nine when
glucose production per kilogram body weight is
beginning to decrease toward adult values. 2 Using
stable isotopically-labeled glucose, it has been
demonstrated that the glucose production rate
per kilogram of body weight during early child-
hood is 2-4 times greater than in adults. 2
The lack of response to glucagon at the time of
symptoms suggests depletion of liver glycogen
stores. Circulating alanine, the primary gluco-
neogenic amino acid, is low. There is, however,
no abnormality in the gluconeogenic pathway.
Certain hypotheses have been put forth for eti-
ology. 2 Briefly they are:
1 ) a primary defect in the catecholamine re-
sponse to hypoglycemia.
2 ) a primary defect in the muscle protein
catabolism during starvation leading to unavail-
ability of gluconeogenic substrates, mainly
alanine.
3 ) a primary defect in the cortisol response
during hypoglycemia.
Treatment and Prognosis
Intravenous glucose is administered to pa-
tients experiencing acute hypoglycemic episodes
who are unresponsive to oral glucose: the symp-
toms remit rapidly. In the interim, a high-
carbohydrate. high-protein diet administered with
extra feeds at bedtime in conjunction with an
early breakfast usually precludes the need for
drug therapy. Parents also are instructed to
monitor urine for ketones every morning and
evening I and every four hours if the child is ill
and has had decreased carbohydrate intake)
since ketonuria is the harbinger of a hypogly-
cemic episode. If ketonuria is present, liquids
containing high concentrations of glucose should
be administered.
Long-term prognosis is good. Risk of mental
retardation and intelligence impairment is pro-
portional to the degree of control and frequency
of the episodes. An association of delayed speech
has been reported in ketotic hypoglycemics but
this is a topic for further research. Some reports
also have linked this disorder to an increased risk
of developing diabetes mellitus, but this also is an
avenue for further research.
References
1. Colie E, Ulstrom R et aL: Ketotic hvpoglvcemia.
J Pcdiatr 1964; 64:632-49.
2. Dahlquist G et aL: Ketotic Hypoglycemia of child-
hood— A clinical triad of several unifying etiological hypo-
theses. Acta Paediatr Scand 1979; 68:649-56.
3. Finegold DN et aL: Glycemic response to glucagon
during histing hypoglycemia: An aid in the diagnosis of
hyperinsulinism. J Pediatr 1980; 96:257-9.
4. Frasier SD: Pediatric Endocrinology , San Fran-
cisco, Grune and Stratton, 1980, pp 305-7.
5. Kempe CH et aL: Current Pediatric Diagnosis and
Treatment, Los Altos, CA, Lange Medical Publications,
1976, pp 639-667, 902-9.
6. Vaughn VE et aL: Nelson’s Textbook of Pediatrics,
Philadelphia, Sanders, 1979, pp 1603-4.
128
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925-4756
MEDICAL STAFF
ADULT PSYCHIATRY
Miroslav Kovacevich, M. D.
Charles C. Weise, M. D.
Thomas S. Knapp, M. D.
Pablo M. Pauig, M. D.
Ralph S. Smith, M. D.
Lee L. Neilan, M. D.
Edmund C. Settle, Jr., M. D.
Gina Puzzuoli, M. D.
John P. MacCallum, M. D.
925-0693
925-2159
925-3554
343-8843
925-0349
925-0349
925-6914
925-6914
925-6966
CHILD PSYCHIATRY
Henrietta L. Marquis, M. D.
Pablo M. Pauig, M. D.
Ralph S Smith, M. D.
John P. MacCallum, M. D.
925-3160
343-8843
925-0349
925-6966
Psychiatric treatment for the emotionally
disturbed children ages 5 to 13 now avail-
able in new children’s pavilion. Separation
maintained from adult psychiatric care
unit. Each program offers:
• Crisis Intervention
• Group Therapy
• Psychotherapy
• Activities & Recreational Therapies
• Skilled Attention to Family, Marital, and
Individual Emotional Problems
• Special Care for the Acutely Disturbed
Patient
• Staffed by Qualified Psychiatrists and
Medical Consultants
• Schooling Provided on Children’s Pa-
vilion
• Serving the Community for Over 25
Years
J
June, 1983, Vol. 79, No. 6
129
*jke PzeAident
ON BECOMING INVOLVED
“T7 very man owes part of his time and money
to the business or industry in which he is
engaged. No man has a moral right to with-
hold his support from an organization that is
striving to improve conditions within its
sphere .” — Teddy Roosevelt.
The above quote is especially applicable to
the professions, and to our profession of
Medicine in particular. Through the years,
physicians have enjoyed a certain respect, al-
most a reverence not accorded to many. There
has been reason for this. It has been earned
by dedication to the welfare of the patient
above all else. The past generations of our
peers have handed us a legacy built on their
self-sacrifice and personal dedication to the
good of the patient. This legacy has sustained
our profession.
Regrettably, this may no longer be true.
Our profession is under attack from all sides
as being cynical, uncaring, greedy and unin-
volved. There seems to be a feeling rampant
across the country and our state that physi-
cians are interested only in taking from their
patients and the community and giving very
little in return. I think this is a false percep-
tion, but it is a far cry from the image of
Medicine as the compassionate, caring pro-
fession it historically has been.
We can correct this perception, I feel, by
becoming more involved, as individuals and
through our organization. It is not enough in
our Association to say, “Let Charlie do it”
(or Harry, or John, or Carl). We each must
take an active interest and become involved
in the efforts of our Association. It is not
enough, in the political arena, to complain
bitterly among ourselves when legislation
contrary to the best interests of our patients
is enacted. We each must take it upon our-
self to investigate the issues, and com-
municate our concerns to our legislators in-
dividually so that they have some knowledge
of the impact of their actions. Those actions
that benefit our patients will, in the long run,
benefit our profession. It may be a cliche to
say, “If you are not part of the solution, you
are part of the problem,” but there does ap-
pear to be truth in this.
We also need to become more involved, per-
sonally and professionally, with our com-
munities. Nowhere else is John Donne’s
comment, “No man is an island . . . ,” more
appropriate. If we physicians are perceived
as a “privileged class” and as takers, not
givers, each individual instance becomes a
reflection on the profession as a whole.
I ask and urge each of you, individually, to
become more involved. The whole is greater
than the sum of all its parts. Any actions of
our organization are the results of the ac-
cumulation of individual actions by con-
cerned, dedicated physicians; and, if more of
us will become more involved and act, the
greater influence we can wield for the benefit
of our patients.
cv
Harry Shannon, M. D., President
West Virginia State Medical Association
130
The West Virginia Medical Journal
The Vest Virginia tledical Journal
Editorials
The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or
in communications submitted to this Journal for publication. The author shall be held entirely responsible.
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State
Medical Association.
For some very practical reasons, state legisla-
tive sessions hardly are models of consistency.
In spite of what many might think. 60 days is not
a long time in which to deal
INCONSISTENCY adequately with budget and
other complex matters, par-
ticularly in the current era.
As a result of this, political and other very
real factors, things happen, and bills are passed,
that often go outside the realm of logic. This
was the case in 1983 in the general arena of
health care costs.
In a near-panic, last-minute move, the Legis-
lature set up a West Virginia Health Care Cost
Review Authority and empowered it to — among
other things — set hospital rates. This Association
regards the act as a poor piece of legislation, for
reasons already expressed in The Journal and
otherwise.
But while it frantically moved to pass this
cumbersome piece of so-called cost containment,
the Legislature also enacted in its closing hours
two other measures that promise to increase
health care outlays.
One requires accident and sickness insurers to
make available coverage for primary health care
nursing services, and thus provides the mecha-
nism sought by the West Virginia Nurses As-
sociation to help registered nurses — irrespective
of levels of training — to move into independent
practice.
The other act makes physical therapists direct
primary care providers by permitting them to
treat persons other than those referred by doc-
tors of medicine and osteopathy, dentists and
podiatrists. State law previously has had the
referral requirement.
The inconsistency in the legislative action is
clear. We have our doubts as to what the effects
of the hospital act really will be. But we know
of no evidence to indicate that creation of new
primary care providers can do anything but
increase the cost of health care to the public.
With respect to the nurses measure, we think
the public can expect to pay increased insurance
premiums for the new coverage, effective next
January 1. The insurance industry feels that
some companies might not want to make the
nurses coverage available, and elect to leave the
state. That remains to be seen, of course, but
West Virginia now is unique with this type of
coverage as a part of statute.
It’s also uncertain just how many nurses or
groups of nurses might enter independent prac-
tice. But with any number at all in such posture,
and physical therapists in a generally similar role
of independence, the picture is clear. More peo-
ple will be after the health care dollar.
We must hasten to stress that the Medical
Association is not anti-nurse or anti-therapist.
It has had a working committee relationship with
the nurses association for years, and there’s no
indication that will change.
Perhaps it’s most fitting, at the moment, to
recall the words a few years ago of the late Miss
Freda Engle, the veteran executive officer of the
West Virginia Board of Examiners for Registered
Professional Nurses.
The health care system. Miss Engle empha-
sized, is just that — a system. Within that system
are appropriate roles for the significant variety of
health care providers, according to their expertise
and training. But the system is of overriding im-
portance.
It has been in that general context that the
Medical Association has worked for several years
with the nurses’ examining board in specific
efforts to develop administrative rules, regula-
tions and realistic guidelines for the most effec-
tive use of advanced registered nurse prac-
titioners.
It’s also significant, perhaps, that in this de-
tailed effort the nurses’ board often has found
physician comments and suggestions more rea-
sonable than those from many nurses — partic-
ularly those who don't have the training enjoyed
by those with advanced degrees.
There’s the further fact of life that to an ever
increasing degree, additional persons and groups
are struggling to get a bigger piece of the health
care turf.
• X
June, 1983, Vol. 79, No. 6
131
It’s disturbing and frustrating — and even
frightening when one considers the basic element
of availability of quality care — to see legislative
action which encourages and even directly con-
tributes to this effort — again, irrespective of edu-
cational and other provider qualifications.
It can be said in many ways, but it can't be
reemphasized too often. “It” is a national issue
of the moment — the critical necessity for more
and more involvement of physicians in public
affairs.
“Complaining about the actions of our elected
representatives must be the second most popular
indoor sport in our country.' ob-
TAKE ACTION served Darrell Cannon. M. D..
the Los Angeles County Medical
Association President. “But what they need
from us now,” Doctor Cannon added, “is input,
not complaints.”
“Physicians could (emphasis ours) have a
profound effect on all important issues,” the
Nebraska Medical Association President, Allan
C. Landers, M. D., recently wrote. “To fail to
do so is to sacrifice a privilege we and our fore-
bearers have earned.”
Doctor Landers stressed that he was not re-
ferring “to strictly medical issues, but to any
issue that affects all citizens. I would encourage
individual input into all levels of government,
spanning the spectrum from local school boards
right up through the Congress of the LInited
States.”
The Nebraska physician then zeroed in on one
of the most pertinent points. “ Others , perhaps
less informed, do it. Why shouldn’t we?”
The Medical Association of the State of Ala-
bama President, Ronald E. Henderson, M. D.,
noted the “multitude of dangers and opportun-
ities facing the medical profession at the present
time. The threat to the independent practice of
medicine is real.” He added:
“Because of the magnitude of change about to
occur, there is the danger that the system that
evolves will represent a threat to the patients
that we serve. On the other hand, however, never
before in your lifetime or mine has there been
such an opportunity to make meaningful contri-
butions.''
Nothing these physicians from other states
have said is new. Our State Medical Association
leadership has emphasized the same general
points. But getting real action, in the form of
individual and collective physician response, re-
mains the critical problem in West Virginia, and
elsewhere.
Contact with legislators, for example, is a
year-around necessity. Little really can be ac-
complished during the short 60 days of an actual
legislative session.
Doctor Cannon urged the Los Angeles physi-
cians to take the time and make the effort to
meet legislators from their areas. Write or call
them about issues that are of concern. And do
this regardless of the calendar.
“Our legislators are trying to resolve major
problems,” Doctor Cannon said. “They will pro-
duce better answers for all of us — doctors and
patients — if we take the time and make the effort
to keep them informed of our opinions and con-
cerns on medical issues.”
Again, there is nothing new nor revolutionary
in this statement. But it sets forth a critical fact
of life. Without much more physician involve-
ment in the world outside the office or hospital.
Medicine and quality medical care face an un-
certain, and perhaps disastrous, future.
Dwight L. Blackburn. M. D., President of the
Kentucky Medical Association, put that same
conclusion this way: “The ultimate survival of
our profession and its ability to endure and serve
succeeding generations is a responsibility each
of us must continue to share.”
Think about all this. And then do something
about it. It’s time and effort you cannot afford
not to find and undertake.
This is June. Next comes July. And then
August, with the Medical Association’s 116th
Annual Meeting. Hopefully, particularly noting
the embattled position in which Medicine and
patient care now are entrenched, physicians
around the state will think more about August
25-27.
Those physicians can have, through their local
society memberships, 154 delegates in the As-
sociation's House of Delegates.
HELP WANTED This is the policy-making body
— potentially the key com-
ponent in organized Medicine here.
In recent years, component societies have
been slow to choose their delegates. Representa-
tion at the Greenbrier has been nothing to write
home about. All of which means that the issues
can't be addressed unless the grass-roots member-
ship does its part.
Selection of delegates lias been slow again
this year. Local societies need to pick up the
pace. The State Association's leadership must
have this kind of help and input if it is to be
effective.
132
The West Virginia Medical Journal
GENERAL NEWS
Internist, Urologist Speakers
For Convention Session
Physicians from Washington, DC, and Akron,
Ohio, will participate in a “Symposium on
Sexually Transmitted Diseases” during the 116th
Annual Meeting of the State Medical Association.
Edmund C. Tramont, M. D., Chief, Infectious
Diseases, Department of Bacterial Diseases, Wal-
ter Reed Army Institute of Research in Wash-
ington, will speak on “Syphilis and Gonococcal
Edmund C. Tramont, M. D. Jack L. Summers, M. D.
Infections,” while Jack L. Summers, M. D., of
Akron will discuss “Sexual Mores in the 1980s.”
Doctor Summers is full-time Chairman of the
Department of Urology at Akron City Hospital
and Professor and Chairman, Department of
Urology, at Northeastern Ohio Universities Col-
lege of Medicine in Akron.
The symposium will constitute the first general
scientific session of the convention Friday morn-
ing, August 26.
The Annual Meeting will be held August 25-
27 at the Greenbrier in White Sulphur Springs.
Other symposium speakers, as announced
previously, will be Lee P. Van Voris, M. D., of
Erie, Pennsylvania, until recently Associate Pro-
fessor of Medicine at Marshall University and
now Chief of Infectious Diseases and Hospital
Epidemiologist at Hamot Hospital in Erie; and
George J. Pazin. M. D., Associate Professor of
Medicine at the University of Pittsburgh. Their
topics, respectively, will be “Non-Luetic, Non-
Gonococcal Venereal Diseases” and “Transmissi-
ble Diseases of the Gay Patient.”
AM A President to Speak
The Annual Meeting will open with a pre-
convention session of the Association’s Council
and the first session of the House of Delegates on
Thursday morning and afternoon, August 25;
and end with the second and final House session
and reception for new Association officers on
Saturday morning and afternoon.
Dr. Frank J. Jirka. Jr., of Barrington, Illinois,
as announced previously, will address the first
House session on Thursday. He will be installed
as President of the American Medical Associa-
tion this month in Chicago.
Doctor Tramont, a colonel in the U. S. Army
Medical Corps, also is Associate Professor of
Medicine and Coordinator (Chief I, Division of
Infectious Diseases, Uniformed Services Uni-
versity of the Health Sciences Medical School,
Bethesda, Maryland; and Clinical Associate Pro-
fessor of Medicine at Georgetown LJniversity in
Washington.
He is a Fellow of the American College of
Physicians and the Infectious Disease Society of
America, a Diplomate of the American Board
of Internal Medicine, and also a Diplomate, in
Infectious Diseases, of that Board.
Doctor Tramont was graduated from Rutgers
University, and received his M. D. degree in
1966 from Boston University. He took his post-
graduate training at Bellevue (Cornell Division)
and Memorial hospitals in New York City, and
at Walter Reed.
Doctor Tramont is the author or co-author of
some 75 scientific articles and abstracts, plus a
number of book reviews.
WVU Graduate
Doctor Summers is a 1966 graduate of West
Virginia University School of Medicine, and
served his internship and urology residency at
Akron City Hospital.
He was in the private practice of urology from
1973 to 1979, at which time he became full-time
Chairman of the Department of Urology at Akron
City Hospital. Doctor Summers also is Clinical
Professor of LIrology at WVU. He currently is
President of the Cleveland Urological Society and
June, 1983, Vol. 79, No. 6
133
President Elect of the Summit County Medical
Society, Akron.
Doctor Summers is pursuing a degree in sex
education at the Institute for the Advanced Study
of Human Sexuality in San Francisco.
Dr. Samuel P. Asper of Philadelphia, also as
announced, will deliver the keynote Thomas L.
Harris address during opening exercises Friday
morning preceding the first general scientific ses-
sion. Doctor Asper, who is President of the
Educational Commission for Foreign Medical
Graduates, will speak on “Strengths and Weak-
nesses of the U. S. Role in International Medi-
cine.
The second and final general scientific session,
a “Symposium on Cardiovascular Diseases,” will
be held Saturday morning. Individual subjects
will include new developments in the manage-
ment of cardiac arrhythmias; an update relative
to cardiovascular surgery; and the management
of congestive heart failure.
Doctor Adkins To Be Installed
At the final House session on Saturday after-
noon, Carl R. Adkins, M. D., of Fayetteville will
he installed as the Association’s 1983-84 Presi-
dent to succeed Harry Shannon, M. D., of Park-
ersburg.
In addition to the House and general sessions,
the Annual Meeting agenda will include break-
fast, luncheon and other programs arranged by
specialty societies and sections, many of which
also will provide scientific discussions.
The specialty group meetings will be held in
large measure on Friday, with a few to be set
for Saturday morning, preceding the second
general session, and at noon.
The Auxiliary to the State Medical Associa-
tion, with Mrs. Richard S. Kerr of Morgantown
Greenbrier Reservations
Due By July 10
Reservations for the 116th Annual Meeting
of the West Virginia State Medical Association
should be made with the Greenbrier no later
than Sunday, July 10, in order to comply with
the hotel’s requirement that all reservations
must be received no later than 45 days prior to
the meeting. Reservation forms provided by
the Greenbrier have been distributed to all
Association members. Any physicians who
need additional forms should write or call the
Association’s headquarters office in Charles-
ton.
the current President, as usual will hold its
meeting in conjunction with that of the Associa-
tion.
Members of the 1983 Program Committee
are David Z. Morgan. M. D., Morgantown,
Chairman; Doctor Adkins; Jean P. Cavender,
M. D., Charleston: Michael J. Lewis, M. D., St.
Marys; Kenneth Scher, M. D., Huntington, and
Roland J. Weisser, Jr., M. D., Morgantown.
Information concerning remaining speakers
and other convention details will be provided
in the July and August issues of The Journal.
Child Abuse, Drunk Driving
Auxiliary Targets
Promoting awareness and prevention of child
abuse and drunk driving will be the focus of the
American Medical Association Auxiliary’s 1983-
84 Shape Up for Life campaign.
In 1979, the AMA Auxiliary launched Shape
Lip for Life, its nationwide program to promote
good health. The Shape Lip for Life campaign
encompasses areas of health such as nutrition,
exercise, stress management, and substance
abuse.
In 1983-84, Shape Up for Life will focus on
Children and Youth, with a special emphasis on
prevention of child abuse. Drunk driving also
will be spotlighted under the Shape Up for Life
umbrella. Promotion of public awareness is the
major concern, with new materials available to
provide information. Two new brochures, en-
titled “Child Abuse Prevention” and “Drinking
and Traffic Safety,” will be available.
Shown above at its April meeting is the Mason
County Medical Society, which has become in-
creasingly active in recent months. At the head of
the table is Dr. Mel P. Simon, Point Pleasant
urologist. President. The meeting was held at
Pleasant Valley Hospital in Point Pleasant.
134
The West Virginia Medical Journal
Continuing Education
Activities
Here are the continuing medical education
activities listed primarily by the West Virginia
University School of Medicine for part of
1983, as compiled by Dr. Robert L. Smith,
Assistant Dean for Continuing Education, and
J. Zeb Wright, Ph. D., Coordinator, Con-
tinuing Education, Department of Community
Medicine, Charleston Division. The schedule is
presented as a convenience for physicians in plan-
ning their continuing education program. (Other
national, state and district medical meetings are
listed in the Medical Meetings Department of
The Journal. )
The program is tentative and subject to
change. It should he noted that weekly confer-
ences also are held on the Morgantown, Charles-
ton and Wheeling campuses. Further information
about these may be obtained from: Division of
Continuing Education. WVU Medical Center.
3110 MacCorkle Avenue, S. E., Charleston
25301: Office of Continuing Medical Education,
WVU Medical Center, Morgantown 26506; or
Office of Continuing Medical Education, Wheel-
ing Division. WVU School of Medicine. Ohio
\ alley Medical Center. 2000 Eoff Street. Wheel-
ing 26003.
June 3-4. Morgantown. Anesthesia Update 83
June 4, Charleston. 10th Annual Wildwater
Conference — Medical & Surgical Update
June 11. Morgantown, Interventional Radiology
Regularly Scheduled Continuing
Education Outreach Programs from
WVU Medical Center/
Charleston Division
Buckhannon, St. Joseph’s Hospital, first-floor
cafeteria. 3rd Thursday. 7-9 P. M. — June
16. ‘‘Sudden Infant Death Syndrome. David
Myerherg, M. D.
Cabin Creel r. Cabin Creek Medical Center,
Dawes, 2nd Wednesday, 8-10 A. M. — June
8, ‘‘ENT Update. ' Ronald L. Wilkinson. M. D.
Cassaway , Braxton Co. Memorial Hospital, 1st
Wednesday. 7-9 P. M. — June 1, “Common
Blood Disorders.” Steven Juhelirer, M. D.
July 6. “The Pharmacology of Hypertension
Management,” Stephen Grubb. M. D.
Aug. 3, “Diagnosis of Pulmonary Disorders,”
Dominic Caziano, M. D.
Madison , 2nd floor, Lick Creek Social Services
Bldg., 2nd Tuesday, 7-9 P. M. — June 14.
“Recently Recognized Sexually — Transmitted
Diseases.” Thomas W. Mou, M. D.
July 12, “Approach to the Peripheral Vascular
Patient. " Ali F. AbuRahma. M. D.
Oak Hill, Oak Hill High School ( Oyler Exit, N
19 1 4th Tuesday, 7-9 P. M. — June 28.
“Protocols for the Treatment of Pit Viper
Bites,” David Wright. VI. D.
Welch, Stevens Clinic Hospital, 3rd Wednesday,
12 l\oon-2 P. M. — June 15, “Low Back
Injury” la special program in cooperation
with Workers’ Compensation Fund of W. \ a.,
speaker to be announced )
W hitesville, Raleigh-Boone Medical Center, 4th
Wednesday, 11 A. M.-l P. M. — June- August
I summer break )
Williamson, Appalachian Power Auditorium, 1st
Thursday, 6:30-8:30 P. M. — June 2. “Proper
Utilization of the Clinical Laboratory. Bobby
Lee Caldwell, M. D.
Management / Lai) Workshops
June 16-17, Beckley
Health delivery management, intestinal para-
sitology. and abnormal white/red blood cell
morphology will be the three workshop subjects
for the Summer Management Laboratory Con-
ference June 16-17 in Beckley at the Ramada
Inn.
Sponsors are Hygeia Facilities in Oceana
and West Virginia University Medical Center,
Charleston Division.
The two-dav parasitology wet workshop will be
conducted by John E. Hall. Ph.D.. Professor of
Microbiology. WVU Medical Center. The hema-
tology workshop, a seven-hour option on the
17th. will be led by William Koss, M.D., Director
of Hematology and Coagulation Laboratories;
Marta J. Henderson. M.S., Department of
Medical Technology: and Deborah A. Jones
VlTlASCPl, Hematology Laboratory, all from
the WVU Medical Center.
The one-day management workshop on June
16 will be conducted by Albert E. Giles and Jon
V. Straumfjord, M. D., Ph.D., Kirkwood, New
Jersey. Current Medicare-Medicaid legislation
‘ X
June, 1983, Vol. 79, No. 6
135
will be among laboratory management topics
covered.
A total of .7 Continuing Education Unit
(CEU ) Credits may be earned each of the two
days. All health professionals are invited, par-
ticularly administrative and technical laboratory
personnel. Registration fee is $20 per day.
Further information and registration forms
may be obtained from Junemarie Bowling,
MT( ASCPl, Conference Chairperson, Hygeia
Facilities, Box 400, Oceana 24870. Telephone
(304) 682-6246 (6247).
Membership Amendments
Set For House Vote
Up for final action at the first session of the
State Medical Association’s House of Delegates
August 25 at the Greenbrier will be constitution
and bylaws amendments to make residents in
their first year of approved training eligible for
Association membership.
Under current state law, those first-year resi-
dents are not eligible for licensure (they work
under an educational training permit issued by
the West Virginia Board of Medicine), and thus
also are not eligible for Association membership
pending licensure.
Here is the language of the proposed consti-
tution and bylaws changes:
AMENDMENTS TO THE CONSTITUTION
( Approved by the Committee on Constitu-
tion and By-Laws, Executive Committee and
the Council, August 25-26, introduced into
House of Delegates August 26, 1982, and
subject to action by the House August 25,
1983.)
Sec. 1. This Association shall consist of active,
retired, honorary, resident and student members.
Sec. 2. Members. Membership in the As-
sociation shall be limited to doctors of medicine
licensed to practice in West Virginia who are
members of a component medical society of the
West Virginia State Medical Association; resi-
dents who are licensed to practice medicine in
W est Virginia, or who are serving in internship I
residency training programs approved by the
West Virginia Board of Medicine prior to meet-
ing requirements for licensure; and students en-
rolled in accredited schools of medicine in West
Virginia granting Doctor of Medicine degrees.
Sec. 6. Resident members shall be those
persons who are licensed to practice medicine in
West Virginia, or who are serving in internship!
residency training programs approved by the
West Virginia Board of Medicine prior to meet-
ing requirements for licensure, and ivho are
qualified for membership under the By-Laws of
this Association.
ARTICLE XIV.— AMENDMENTS
Sec. 1. The House of Delegates may amend
any article of this Constitution by a two-thirds
vote of the delegates present at any annual ses-
sion, provided that such amendment shall have
been presented in open meeting at the previous
annual session, and that it shall have been
published twice during the year in THE WEST
VIRGINIA MEDICAL JOURNAL, or sent
officially to each component society, and resi-
dent and student members whose names are
listed on the official roster of the Association at
Review A Book
Phe following books have been received by the
Headquarters Office of the State Medical Associa-
tion. Medical readers interested in reviewing any
of these volumes should address their requests to
Editor, The West Virginia Medical Journal, Post
Office Box 1031, Charleston 25324. We shall be
happy to send the books to you, and you may
keep them for your personal libraries after sub-
mitting to The Journal a review for publication.
Basic and Clinical Pharmacology, by Bertram
G. Katzung, M. D., Ph.D. 815 pages. Price
$23.50. Lange Medical Publications, Los Altos,
California 94022. 1982.
Current Medical Diagnosis and Treatment,
1983, edited by Marcus A. Krupp, M. D.; and
Milton J. Chatton, M. D. 1130 pages. Price $24.
Lange Medical Publications, Los Altos, Cali-
fornia 94022. 1983.
General Ophthalmology, 10th Edition, by
Daniel Vaughan, M. D.; and Taylor Asbury,
M. D. 407 pages. Price $17. Lange Medical
Publications, Los Altos, California 94022.
1983.
Neuroanatomy. An Atlas of Structures, Sec-
tions, and Systems, by Duane E. Haines, Ph.D.,
Professor of Anatomy, West Virginia University
School of Medicine, Morgantown. 212 pages.
Price $19.50. Urban & Schwarzenberg Medical
Publishers, 7 East Redwood Street, Baltimore,
Maryland 21202. 1983.
136
The West Virginia Medical Journal
least two months before the meeting at which
final action is to be taken.
( Words in italics indicate new portion to be
added or a change in old verbage. The purpose
of the amendments is to provide eligibility for
State Association membership for interns/resi-
dents in their first year of approved training,
before they can be licensed under state law.)
AMENDMENT TO THE BY-LAWS
(Approved by the Committee on Constitu-
tion and By-Laws, Executive Committee and
the Council. August 25-26, also introduced
in House August 26, 1982. and now await-
ing action by the House August 25, 1983.)
Sec. 1. The name of a physician on the
properly certified roster of members of a com-
ponent society shall be prima facie evidence of
membership in this Association, provided he has
paid local and state dues and any current as-
sessment, and provided further that he is licensed
to practice medicine in West Virginia. The
membership also shall include, upon payment of
state dues and any current assessment; a resident
licensed to practice medicine in West Virginia,
or who is serving in an internship residency
training program approved by the West Virginia
Board of Medicine prior to meeting requirements
for licensure; and a student enrolled and working
toward a Doctor of Medicine degree, in any
accredited school of medicine in West Virginia:
provided, further, that the academic status of
each medical student applicant for membership
shall be certified by the dean of his medical
school.
Sec. 4. Each member in attendance at an an-
nual session shall register and indicate the com-
ponent society, or Resident or Medical Student
Section, of which he is a member. When his
right to membership has been verified by
reference to the roster of his society, Resident
or Medical Student Section, he shall receive a
badge which shall be evidence of his right to all
privileges of membership at that session. No
member shall take part in any of the proceedings
of an annual session until he has complied with
the provisions of this Section.
(Note: New language is set in italics. The
amendment would make an intern /resident in
his first year of approved training, and prior to
licensure under state law, eligible for State Medi-
cal Association membership and thus provide for
implementation of the preceding constitutional
amendment. )
ACP Fellow
Dr. Thomas W. Mou of Charleston was named
a Fellow of the American College of Physicians
at the organization’s recent annual meeting in
San Francisco. Doctor Mou is Dean of the
Charleston Division, West Virginia Medical Cen-
ter, and former Acting Vice Chancellor for the
West Virginia Board of Regents (1979-82).
Dr. Earl L. Fisher of Gassaway, whose career spans nearly 50 years, received the “Mister Doc” Award,
the highest honor bestowed by the West Virginia Chapter, American Academy of Family Physicians, during
the Academy’s annual scientific assembly held recently in Morgantown. In the left photo. Doctor Fisher and
some of his family are shown following presentation of the award. In the right photo are new AAFP officers
for 1983-84 who were installed during the meeting. They are, from left, Drs. William H. Harriman, Jr., Terra
Alta, President Elect; Joseph B. Reed, Buckhannon, Vice President; Michael J. Lewis, St. Marys, Secretary;
Robert D. Hess, Clarksburg, Chairman of the Board; A. Paul Brooks, Jr., Parkersburg, President; John L.
Fullmer, Morgantown, Alternate Delegate, AAFP; and L. Dale Simmons, Clarksburg, Delegate, AAFP. Not
shown is Dr. John V. Merrifield, Charleston, Treasurer.
' 3 |
June, 1983, Vol. 79, No. 6
137
aHVUS >1
AMA House of Delegates
Meets June 19-23
The annual meeting of the American Medical
Association’s House of Delegates will be held
June 19-23 in Chicago at the Marriott Hotel.
The West Virginia State Medical Association’s
two Delegates to the AMA House of Delegates
are Drs. Frank J. Holroyd of Princeton and
Frank J. Holroyd, M. D. Harry S. Weeks, Jr., M. D
Harry S. Weeks, Jr., of Wheeling, with Drs.
Jack Leckie of Huntington and Joseph A. Smith
of Dunbar as Alternate Delegates.
The House of Delegates is composed of repre-
sentatives from state medical associations, na-
tional medical specialty societies, resident physi-
cians, medical students, medical schools and
other medical groups.
Dr. William Y. Rial of Swarthmore, Pennsyl-
vania, is President of the AMA. President Elect
is Frank J. Jirka, M. D., of Barrington Hills.
Illinois, who will assume the presidency during
the meeting.
New Feature
The program for the State Association’s An-
nual Meeting August 25-27 at The Greenbrier
will have a new feature. Being arranged for
Saturday night is a dinner open to the member-
ship to honor the new Association and Auxiliary
officers, and recognize those who have served in
1982-83.
T1 ie black-tie affair s guests will include visit-
ing Presidents from other states and their
spouses, and from the American Medical Asso-
ciation. Ticket and other information will he
forthcoming in July and August issues of The
Journal. The Auxiliary’s current plans are to
delete from its activities a Friday night social
affair it has held for some time, and to partici-
pate in the August 27 dinner.
Medical Meetings
June 5-9 — Am. Society of Colon & Rectal Surgeons,
Boston.
June 7-10 — Society of Nuclear Medicine, St. Louis.
June 16-17 — Summer Management/Laboratory Con-
ference (Hygeia Facilities and WVU Medical
Center, Charleston Div.), Beckley.
June 17-18 — Society for Vascular Surgery, San
Francisco.
June 19-23- Annual Meeting of AMA House, Chi-
cago.
June 22-25 — Am. College of Surgeons, Eastsound,
WA.
June 23-26 — Am. Medical Women’s Assoc., Minne-
apolis.
Aug. 25-27 — 116th Annual Meeting, W. Va. State
Medical Assn., White Sulphur Springs.
Sept. 29-Oet. 1 — Am. Assoc, for the Surgery of
Trauma.
Sept. 29-Oct. 2 — Am. Society of Internal Medicine,
San Francisco.
Oct. 2-5 — Am. Neurological Assoc., New Orleans.
Oct. 5-8 — Am. Thyroid Assoc., New Orleans.
Oct. 16-21 — Am. College of Surgeons, Atlanta.
Oct. 22-27 — Am. Academy of Pediatrics, San Fran-
cisco.
Oct. 23-27 — Am. College of Chest Physicians,
Chicago.
Oct. 23-29 — Am. College of Gastroenterology, Los
Angeles.
Oct. 24-27— Am. College of Emergency Physicians,
Atlanta.
Nov. 6-9 — Scientific Assembly, Southern Medical
Assoc., Baltimore.
Nov. 30-Dec. 1 — Am. College of Chemosurgery,
Chicago.
1984
Jan. 27-29 — 17th Mid-Winter Clinical Conference,
Charleston.
March 17 — Annual Meeting, W. Va. Affiliate,
American Diabetes Assoc., Wheeling.
138
The West Virginia Medical Journal
WHY BMW CHOSE
TO CHANGE THE
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So after six years the sedan Car and Driver nominated “the quintessential
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machine with a totally redesigned, fully independent suspension system, new
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WVU Medical Center
-News-
Compiled from material furnished by the Medical Center
News Service, Morgantown, W. Va.
Toxic Shock Still Problem
As Publicity Dwindles
Toxic shock syndrome continues to be a
medical problem despite removal from the
market of high absorbency tampons believed to
predispose menstruating women to infection.
In fact, 10 per cent of all cases diagnosed as
toxic shock syndrome have no direct relation to
menstruation, according to Larry G. Reimer,
M. D., Director of the Clinical Microbiology
Laboratory.
Doctor Reimer, who also is Assistant Professor
of Medicine and Pathology, said public aware-
ness probably bad resulted in patients seeking
medical help earlier and a lowering of the
mortality rate.
“But on the other hand, a lot of publicity
about toxic shock syndrome has now died down,”
he said. “Some physicians may have reached
a point where they think it’s not a problem any-
more.
Not Always Recognized
“That’s really not the case. Of the three
patients treated at the Medical Center since the
first of the year, one had been seen by two or
three physicians before diagnosis. So it’s not
something that everybody immediately recog-
nizes even now.
“Staphylococcus aureus is a commonly occur-
ring bacteria,” he explained. “Anywhere from
20 to 40 per cent of all women will have it in
vaginal cultures. Just having the organism there
doesn’t say anything about toxic shock.”
But a large growth of the microorganism com-
bined with typical symptoms would confirm the
diagnosis after other diseases such as scarlet
fever, scalded skin syndrome. Rocky Mountain
spotted fever or measles had been ruled out.
Symptoms are a fever of more than 101 F.,
a systolic blood pressure reading of less than 90,
a rash and multi-system involvement manifested
by mental confusion, nausea and vomiting,
diarrhea, kidney or liver impairment, anemia, or
decreased blood clotting elements.
“If we get a vaginal culture that grows a large
amount of staph aureus, we always call the
physician because the laboratory slips don’t
always tell us what diagnosis is being con-
sidered,” Doctor Reimer said.
“If we know the clinical diagnosis of toxic
shock syndrome is suspected, we specifically look
for staph aureus.”
The illness is caused by a toxin secreted by the
bacteria, Doctor Reimer said. Those cases not
associated with menstruation occur when the
microorganism enters the body through surgical
wounds, skin lesions or following childbirth. In
the case of surgical wounds, there is usually no
local inflammation, pain or tenderness.
Female Donors’ Blood Depletion
Faster, Says Researcher
A WVU Medical Center researcher against
equal rights for women?
No, but S. N. Jagannathan, Ph.D., is against
a U. S. Food and Drug Administration rule
which does not discriminate between men and
women when it comes to frequency of repeat
blood donations.
Doctor Jagannathan recently told the Federa-
tion of American Societies for Experimental
Biology his study indicates that maximum giving
can deplete the body’s iron storage status and
that women are much more at risk than men.
Doctor Jagannathan, Associate Professor of
Pathology and Biochemistry, and graduate
student Cary Stoner studied 328 blood donors.
Current FDA rules, approved by the American
Association of Blood Banks, let male and female
donors give a unit of blood every eight weeks.
Doctor Jagannathan said his investigation shows
that at the present eight-week limit, donors’ iron
stores do not get replenished from the typical
American diet alone.
xvi
The West Virginia Medical Journal
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1200 Harrison Avenue
ELKINS, WEST VIRGINIA
ANESTHESIOLOGY:
Y. H. Chung, M. D.
COMMUNITY MEDICINE:
R. C. Gow, M. D.
(Thomas Clinic)
S. O. Chung, M. D.
M. C. Rosenberg, D. O.
(Helvetia Clinic)
EMERGENCY MEDICINE:
R. H. Plummer, D. O.
A. M. Fuller, M. D.
F. A. Khan, M. D.
D. J. Lloyd, M. D.
FAMILY PRACTICE:
L. H. Valliant, M. D.
C. S. High, M. D.
INTERNAL MEDICINE:
Gastroenterology:
S. S. Masilamani, M. D.
Allergy & Rheumatology:
J. B Magee, M. D.
Cardiology:
H. L. Jellinek, M. D.
R. B. Garrett, M. D.
Metabolic & Endocrine Diseases:
F. Becerra, M. D.
Pulmonary Diseases:
J. C. Arnett, Jr., M. D.
OBSTETRICS & GYNECOLOGY:
H. H. Cook, Jr., M. D.
J. F. de Courten, M. D.
J. J. Rizzo, M. D.
M. W. Strider, M. D.
OPHTHALMOLOGY:
J. N. Black, M. D.
ORTHOPAEDIC SURGERY:
J. G. Gomez, M. D.
OTOLARYNGOLOGY
(Facial Plastic and
Reconstructive Surgery):
J. A. Wolfe, M. D.
PATHOLOGY:
M. M. Stump, M. D.
PEDIATRICS:
Y. J. Kwon, M. D.
R. J. Haas, M. D.
PSYCHIATRY:
R. W. O'Donnell, M. D.
RADIOLOGY:
F. H. Abdalla, M. D.
H. Y. Mang, M. D.
C. P. O'Sullivan, M. D.
SURGERY:
General, Thoracic & Vascular:
J. A. Noronha, M. D.
W. B. Blum, M. D.
B. R. Blackburn, M. D.
R. A. Rose, M. D.
UROLOGY:
D. T. Chua, M. D.
June, 1983, Vol. 79, No. 6
XVII
Third-Party News, Views
and Program Concerns
Welfare Clarifies Medicaid
Office Visit Coverage
The West Virginia Department of Welfare is
providing clarification for the state’s physicians
relative to coverage of office visits under the
Medicaid Program. Current experience is re-
flecting some apparent misunderstanding of such
coverage.
The program coverage provides reimburse-
ment for one medical service per day; i.e., Medi-
caid covers one “visit procedure” daily. Further
amplification of this provision will be provided
in notices to individual doctors.
Because of processing program errors, pay-
ment has been made in tbe past for a combina-
tion of daily visits. Now, as tbe erroneous pay-
ments might be identified, physicians will be
notified and steps taken to adjust tbe claims.
In the future, the Department explained, such
combination claims will bring a denial for pay-
ment. A remittance statement will read, “This
claim conflicts with a previously submitted
claim. Tbe conflicting claim (tbe paid claim)
also will be listed on the remittance voucher.
The Department said some examples of con-
flicting service situations have been identified
as an office visit and a home visit in one day;
office visit and nursing home visit; office visit
and emergency room visit; emergency room visit
and hospital visit; office visit and hospital visit;
office visit and consultation; nursing home visit
and office visit, and surgery and another type
of visit.
Reagan Applauds Free Care
For U.S. Unemployed
President Reagan has applauded voluntary
efforts by state, county and national specialty
societies to provide free and low-cost medical
care to tbe nation’s unemployed. In a recent
White House meeting commemorating National
Volunteer Week, medical society representatives
told the President about their programs for
xviii
“newly needy” patients who are ineligible for
Medicare and Medicaid, have no health in-
surance. or are otherwise unable to pay. Tbe
programs included free clinics, health screening,
and no-cost or low-cost medical and surgical
services.
AMA President William Y. Rial. M. D., pre-
sented Reagan with a report on 23 health pro-
grams for the unemployed. Reagan told Doctor
Rial, “You know how strongly I believe in the
power of private sector initiatives — almost as
much as some of those old home remedies that
my mother used to use. One thing is for sure,
I know that local efforts such as those I’ve just
heard about can help tremendously in curing tbe
ills of our country.”
New Ways To Protect Newborns
With Handicap Explored
American Medical Association representatives
met recently with U. S. Department of Health
and Human Services officials to discuss alterna-
tive approaches for implementing the White
House mandate to protect severely handicapped
newborns. Earlier, U. S. District Court Judge
Gerhard A. Gesell had struck down new federal
regulations that required hospitals to post notices
in delivery rooms and nurseries publicizing a
24-hour, toll-free hot line to be used in cases of
suspected neglect.
Following Judge Gesell’s ruling, AMA staff
and representatives from tbe American Academy
of Pediatrics, American College of Obstetrics
and Gynecology. Federation of American Hos-
pitals, American Hospital Association, and tbe
National Association of Children’s Hospitals met
for two hours with John Svahn, Undersecretary
of Health and Human Services, and C. Everett
koop. M. D.. Surgeon General of the U. S.
Public Health Service. The medical organiza-
tions were unanimous in their opposition to the
rulemaking, and advised HHS to enlist the
cooperation of the professional community.
The West Virginia Medical Journal
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June. 1983, Vol. 79, No. 6
XIX
Obituaries
WILLIAM E. ANDERSON, M. D.
Dr. William E. Anderson of Cumberland.
Maryland, formerly of Morgantown, died on
April 4 in Cumberland. A gastroenterologist, be
was 55.
Doctor Anderson was a member of the faculty
of the West Virginia University School of Medi-
cine from 1960 to 1980. when be resigned to
begin group practice in Cumberland. He was
head of the Gastroenterology Section at WVU.
A native of Mankato, Minnesota, Doctor
Anderson was graduated from Gustavus Adolphus
College in St. Peter. Minnesota, and received bis
M. D. degree in 1954 from the University of
Minnesota.
He was a former member of the Monongalia
County Medical Society and the West Virginia
State Medical Association.
Survivors include the widow: a son, Evan
Anderson, at home; the stepmother, Mrs. Evan
Anderson of San Francisco, and a brother. Dr.
Richard Anderson of Eugene, Oregon.
SPENCER L. BIVENS, M. D.
Dr. Spencer L. Bivens, retired Charleston
surgeon, died on May 3 in a nursing home there.
He was 82.
A veteran of World War II, Doctor Bivens
was President of the Kanawha Medical Society
in 1947.
He was born in Meadow Bluff f Greenbrier
County ) .
Doctor Bivens received his M. D. degree in
1928 from Emory University, and completed
postgraduate work at Maryland General Hospital
in Baltimore and Charleston General Hospital.
He was an honorary member of the Kanawha
Medical Society, West Virginia State Medical
Association and American Medical Association.
Survivors include a son. Dr. Spencer E. Bivens,
Jr., of Charleston: a daughter, Mrs. Sara Dawkins
of Marietta. Georgia; and a brother. Carl Bivens
of Alderson.
* # *
RICHARD W. WINGFIELD, M. I).
Word has been received by The Journal of the
death of Dr. Richard W. Wingfield on January
7 in Keller, Virginia. He was 57.
A native of Elkins, Doctor Wingfield was
graduated from West Virginia University, and
received his M. D. degree in 1952 from the
Medical College of Virginia.
Survivors include the widow and three sons,
all of Keller.
* * *
JAMES E. WOTRING, M. D.
Dr. J ames E. Wotring of Fairview ( Marion
County), retired family physician, died on
March 5 in a Morgantown hospital. He was 61.
Doctor Wotring was a former member and
President ( 1963-64 ) of the Marion County
Medical Society, and a former member of the
West Virginia State Medical Association.
Survivors include the widow; two daughters.
Mrs. Ronnie Tucker of Morgantown and Mrs.
Paul Cams of Latrobe, Pennsylvania: four
brothers. Ernest H. Wotring of Marshall, Texas;
Daniel J. Wotring. Jr., of Clinton, Maryland:
Donald R. Wotring of Artesina, New Mexico,
and William R. Wotring of Morgantown; and
three sisters, Mary Shafer of Marlinton, Eleanor
Wotring of Morgantown and Mrs. Edward
Warsinsky of Morgantown.
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xx
The West Virginia Medical Journal
County Societies
McDowell
The McDowell County Medical Society met on
April 13 in Welch at Stevens Clinic Hospital.
Dr. John Goldman. Assistant Professor of
Medicine, Rheumatology and Immunology, at
Emory University in Atlanta, was guest speaker.
His subject was the management of rheumatic
diseases. He stressed the importance of a physi-
cal therapy program for the rheumatic patient.
The Society voted to make a donation equal
to the 1982 amount to Camp Kno Koma. — John
S. Cook. M. D., Secretary.
# # «
TYGART’S VALLEY
Dr. Charles Howell, a psychologist from the
Appalachian Mental Health Center in Buck-
hannon, presented a workshop on “Instant
Aging ' for the meeting of the Tygart’s Valley
Medical Society on April 21.
Held at Broaddus Hospital in Philippi, the
purpose of the workshop was to enable volunteer
participants from the audience to experience and
understand the age-related medical complaints
of the elderly, particularly the low-grade chronic
losses in their daily routine.
The volunteer subjects were “instantly aged”
by plugging their ears with cotton halls, wearing
rubber gloves and taping the joints of the hands,
wearing goggles smeared with mineral oil. etc.
-Halherto G. Cruz, M. D., Secretary.
# # #
FAYETTE
The Fayette County Medical Society held a
combined meeting with its Auxiliary on April
6 at the White Oak Country Club in Oak Hill.
The guest speaker was the Honorable Judge
Robert Abbot, who discussed criminal law, and
compared the English and American judicial
systems. — Serafino S. Maduedoc, Jr., M. D.,
Secretary-T reasurer.
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OPHTHALMOLOGY
Robert K. Modlin, M. D.
Helen R. Perez, M. D.
Robert K. Scott, II, M. D.
Thomas F. Mann, M. D.
PEDIATRICS
Anthony C. Dougherty, M. D.
Williams S. Dukart, M. D.
SURGERY
Janice Centa, P. A., M. S.
General & Vascular
RADIOLOGY
H. P. Dinsmore, M. D.
Charles Weinstein, M. D.
General & Thoracic
B. L. Plybon, M. D.
PSYCHOLOGY
ORTHOPEDIC SURGERY
Connie Bradley-Mann, Ph. D.
Conrad D. Tamea, Jr., M. D.
ANCILLARY SERVICES
James W. Banks, M. D.
Physical Therapy
FAMILY GENERAL PRACTICE
Tom Moore, R. T.
Joseph E. Shaver, M. D.
Wood McCue, R. T.
E. T. Cobb, M. D.
Respiratory Therapy
OBSTETRICS/GYNECOLOGY
James D. Creasman, R.R.T.
James L. Pfeiff, M. D.
Audiology
Robert L. Wheeler, M. D.
Gary M. Vandevander, M.S.
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Amir A. Alidina, M. D.
Sandra W. Ayers, Business Manager
June, 1983, Vol. 79, No. 6
XXI
Professional
Liability Insurance
Designed for
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Reprinted from The West Virginia Medical Journal, September 1981
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• A five-year market guarantee with Continental Casualty Company,
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• A consent to settle provision for doctors covered under the plan.
• An in-state managing general agent, McDonough Caperton Shepherd
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The West Virginia Hedicai Journal
Vol. 79, No. 7 July, 1983
Value And Limitations Of The Noninvasive Laboratory:
Experience With Over 5,000 Patients
ALI F. ABURAHMA, M. D.
Director, Noninvasive Vascular Laboratory, Charleston
Area Medical Center, Charleston, West Virginia; and
Clinical Associate Professor in Surgery, West Virginia
University Medical Center, Charleston Division.
LINDA OSBORNE. L.P.N.
Vascular Technologist, Charleston
Today , the physician is assisted in the manage-
ment of vascular diseases by the various non-
invasive diagnostic modalities offered by the
vascular laboratory. The idea of having a
vascular laboratory has become popular in most
of the major medical centers in the last decade.
In 1978, a vascular laboratory was established
at the Charleston Area Medical Center to provide
diagnostic testing for carotid artery disease or
cerebral ischemia, arterial occlusive disease of
lower and upper extremities, and deep vein
thrombosis of the extremities.
The purpose of this article is to define the
value of the noninvasive vascular laboratory in
the diagnosis of vascular disorders, to describe
some of its occasional limitations, and to present
the results of over 5,000 patients tested in the
laboratory from August, 1978, through March,
1982. Emphasis is placed on tests available in
our laboratory.
Carotid Artery Disease
Various noninvasive diagnostic modalities
have been described for the diagnosis of
carotid artery stenosis; e.g., oculoplethysmo-
graphy (OPG); Doppler ultrasound (continuous
wave); ophthalmodynamometry; thermography;
pulsed Doppler arteriogram; B-image scanning;
real-time, B-image scanning; spectrum sound
analysis; new duplex scanning; color-coded
Doppler ultrasound (echo-flow), and carotid
phonoangiography (CPA). Table 1 shows what
is available in the laboratory.
There are essentially two types of oculople-
thysmography (OPG) devices:
Ocular Pulse Timing OPG ( Kartchner-OPG
and Zira OPG). This test is based on compari-
son of the time of arrival of the arterial pulse at
each eye. When no disease is present, both
pulses arrive simultaneously. Pulse delay in one
eye usually signifies a narrowing or blockage of
the internal carotid artery on the affected side;
e.g., left internal carotid artery stenosis produces
a delayed pulse to the left eye and thus a visible
delay in the left ocular wave tracing (Figure la
& b).
Ophthalmic Artery Pressure OPG ( Pneu-
mooculoplethysmography ) iOPG-Gee) . This
test is based on comparison of the two ophthal-
mic systolic pressures with each other and with
the supine brachial systolic pressure. Using
certain guidelines outlined by Doctor Gee in his
TABLE 1
What Is Available in the CAMC Vascular Laboratory
For the Noninvasive Diagnosis of
Carotid Artery Stenosis
1. Oculoplethysmography (OPG/Zira)
2. Oculoplethysmography (OPG/Gee)®
3. Carotid Phonoangiography (CPA)
4. Carotid arterial Doppler ultrasound
5. Real-time B-image carotid scanner®
°The tests we recommend currently
July, 1983, Vol. 79, No. 7
139
original work on this machine, 11 the diagnosis of
significant carotid stenosis can be made I Figure
lc).
Figure la. An oculoplethysmography (OPG) of a
patient with left carotid artery stenosis.
Figure lb. Carotid arteriogram showing the left
carotid stenosis.
Figure lc. OPG-Gee technique.
Clinical Experience
Using pulse timing OPG, 161 patients (309
carotid arteries I from 2,300 OPGs done at
Charleston Division, West Virginia University
Medical Center, from September, 1978, to
September, 1981, were studied in comparison
with the carotid arteriograms. The age range
was 36 to 78 years.
All the angiograms were reviewed by a
radiologist and one or two vascular surgeons. For
practical purposes, the radiological findings were
classified as follows: a normal carotid artery,
mild disease, less than 40-per cent stenosis; sig-
nificant stenosis, > 40-per cent up to 99-per cent
stenosis; and total occlusion. The results are
shown in Table 2.
We concluded that OPG is valuable in the
diagnosis of normal carotid arteries, unilateral
significant carotid stenosis, significant carotid
stenosis on one side and mild stenosis on the
other side, and unilateral complete carotid
occlusion. We also concluded that OPG has
limited value (around 56 per cent) in the diag-
nosis of bilateral significant carotid stenosis.
Of 550 patients using OPG/Gee, 100 had
arteriograms. Results are shown in Table 3. We
concluded that OPG/Gee is more valuable in
the diagnosis of both unilateral and bilateral
significant carotid stenosis ( 90.3 per cent and
90.4 per cent).
TABLE 2
Correlation of Pulse Timing OPG With Arteriogram
Bilateral Carotid Disease
r o 5
s 8
: a
± .52
l itr'-w ©
* s 2 8
i.Sf « £
3 GoO C/5
8 c-
*2 J’C
£
© © c
OPG/Zira
101
61
32
15 47
13
Arteriogram
92
53
40
27 67
12
Accuracy
91%
87%
80%
56% 70%
92%
TABLE 3
Correlation of OPG/Gee With Arteriogram
Normal
Unilateral
significant
stenosis
Bilateral
significant
stenosis
Total
Arteriogram
48
31
21
100
OPG/Gee
45
28
19
92
Accuracy
94%
90.3%
90.4%
92%
140
Tiif. West Virginia Medical Journal
Discussion
The value of the OPG has been well estab-
lished in the diagnosis of significant carotid
artery stenosis. 2,5,n ’ 12,13 ’ 14 It is to be noted that
neither the OPG nor any indirect method has
been of value in detecting any hemodynamically
non-significant carotid stenosis of less than 40
per cent. Those nonsignificant stenoses can be
associated with ulcers which have the ability to
cause embolization (transient ischemic attack).
Many advantages of OPG give evidence of its
practicality. OPG is administered quickly and in-
expensively. While being well-tolerated by the
patient, it allows for identification of significant
carotid stenotic lesions. Certain limitations, how-
ever, must be noted. The accuracy is poor in
nonhemodynamically significant stenosis of less
than 40- or 50-per cent stenosis. It cannot
identify an ulcerative plaque if not associated
with significant stenosis. Sometimes, differentia-
tion between severe stenosis and complete occlu-
sion cannot be determined. Some OPGs are
limited in bilateral significant stenosis.
B-Mode Image Carotid Scanning
(and Real-Time, B-Image Scanning)
Now available are instruments producing gray-
scale images of high resolution and accurately
identifying atherosclerotic disease at or near the
carotid arterial bifurcation. Real-time presenta-
tion of these images using a hand-held trans-
ducer provides an immediate visualization of the
lesion and reduces problems associated with
locating the artery and positioning the patient.
Videotapes of the images can be stored for
reevaluation or comparison with previous or sub-
sequent scan data (Figure 2a through e). These
Figure 2a. The real-time-B-mode-carotid image
scanner.
direct methods, particularly the real-time, B-
image scanner, visualize the carotid artery
directly and detect even mild stenotic lesions as
compared with the OPG.
In our laboratory, we presently combine both
OPG/Gee and the real-time carotid image scan-
ner.
The recommended protocol for the diagnosis
of carotid artery disease is shown in Figure 3.
Arterial Occlusive Disease
of Lower Extremities
Testing for arterial occlusive disease of the
lower extremities employs various noninvasive
modalities which have been described in the
diagnosis of peripheral vascular occlusive diseases
iPVOD); e.g., pulse volume detectors: thermo-
graphy; Doppler ultrasound (continuous wave);
plethysmography: pulsed Doppler arteriography;
Figure 2b. Real-time, B-image-carotid scan show-
ing normal common carotid (CC), internal carotid
(IC) and external carotid (EC).
Figure 2c. Real-time, B-image scan showing mild
stenosis at the carotid bifurcation.
r*
July, 1983, Vol. 79, No. 7
141
B-image scanning; real-time, B-image scanning:
new duplex scanner, and spectrum sound
analysis.
The most common method being used in this
country is the Doppler ultrasound instrumenta-
tion (continuous wave). This method is em-
ployed in our vascular laboratory. The value of
the Doppler ultrasound in the diagnosis of
peripheral vascular occlusive disease has been
well documented. 1,3, 4,6,16,17
Clinical Material, Methods and Results
Between August, 1978, and March. 1982,
1,080 patients had arterial leg Doppler studies
Figure 2d. Real-time, B-image scan showing com-
plete occlusion of the internal carotid artery (CC:
common carotid, EC: external carotid, and IJV:
internal jugular vein).
Figure 2e. The same patient (2d) with complete
occlusion of the internal carotid artery (arteriogram).
(ALD I with or without exercise. Table 4 shows
the indications for these tests. We selected the
first 150 patients (300 limbs) who had both
ALD and arteriograms for this study.
Each limb was studied in four arterial seg-
ments: 300 iliofemoral, 300 femoral, 282
popliteal, and 275 trifurcation segments.
Eighteen popliteal and 25 trifurcation segments
were excluded because of the lack of angio-
graphic visualization (not enough dye).
Every arterial Doppler examination consisted
of an evaluation of segmental leg pressures,
analysis of the leg pressures in correlation with
the arm pressures (ankle /arm index), arterial
wave tracing, and, if indicated, an exercise test.
The arm systolic pressure and the segmental leg
pressures were recorded from blood pressure
TABLE 4
Indications for Arterial Doppler Examination
1. Calf pain while walking.
2. Leg pain at rest.
3. Skin changes suggestive of arterial insufficiency.
4. Nonhealing ulcers.
5. Previous vascular reconstructive procedures.
TABLE 5
Segmental Pressure and Ankle/Arm Index in a
Patient With Occlusion of the Left Superficial
Femoral Artery
Resting
Right
( Normal )
Left
( Abnormal )
Arm
150
160
High thigh
200
206
Above knee
184
150
Below knee
168
144
Ankle (posterior tibial)
150
128
Ankle (dorsalis pedis)
150
128
Ankle/arm index
(150/150)1.0
(128/160). 80
^-Positive
OPC/Cee^^^
Negative
► Angiogra
» No Symptoms (No
111
TIA)— ► ( )bserve
1
Negative
with
TIA
Real-Time Carotid Image Scanner
No more symptoms Frequent symptoms
* I
Observe & Follow-up Angiogram ?
Figure 3. Recommended protocol for the diagnosis
of carotid artery disease.
142
The West Virginia Medical Journal
cuffs placed at the high area of the thigh, above
the knee, below the knee, and at the ankle
I Figure 4 ) . Resting segmental systolic pressures
were taken at each level, and the highest reading
of the posterior tibial and dorsalis pedis systolic
pressures was used as the ankle pressure. The
ankle/arm index was then calculated. The pres-
ence of greater than 30 mm. Hg gradient be-
tween any adjacent level in the leg indicates sig-
nificant occlusive disease (Table 5).
TABLE 6
Segmental Pressure Reading and Ankle/Arm Index
After Exercise in a Patient With Severe Peripheral
Vascular Occlusive Disease of the Left Leg
After Exercise
Right Ankle
( Normal )
Left Ankle
( Abnormal )
Arm
1 minute
186
50
180
2 minutes
186
58
180
4 minutes
180
60
176
6 minutes
180
70
170
10 minutes
166
78
160
15 minutes
170
90
162
20 minutes
170
130
162
Ankle/arm index
(186/180)1.03
(50/180)0.27
Normal Abnormal
Ankle/Arm Index Ankle/Arm Index
f
Figure 4. Arterial leg Doppler study showing the
segmental Doppler pressures. Note that this study
shows significant stenosis of the left superficial
femoral artery.
Minimal and/or moderate disease is some-
times not manifested without exercise, so exer-
cise tests are done if indicated. The ankle/arm
pressures are then taken after exercise and re-
corded at timed intervals until they return to
pre-exercise levels (Table 6). The blood flow is
indirectly assessed by determining the velocity
in the form of analogue wave tracings. Normally,
an analogue wave tracing has a sharp systolic
and one or more diastolic components. Abnormal
tracings caused by atherosclerotic disease may
show a lack of diastolic components and/or
diminished systolic components (Figure 5).
The results are shown in Table 7. We con-
cluded that this method is very helpful in the
diagnosis of arterial occlusive disease of the
lower extremities with 94-per cent accuracy.
Deep Vein Thrombosis of Lower Extremities
The fallibility of the clinical diagnosis of deep
venous thrombosis (DVT) has led to a variety
TABLE 7
Correlation of Arterial Doppler Studies and
Arteriograms (Total Segments Studied)
Total segments
studied hy
Segments Arterial Doppler
Findings
confirmed hy
Arteriograms
% Accuracy
Iliofemoral
300
282
93%
Femoral
300
280
95%
Popliteal
282
262
94%
Trifurcation
275
262
94%
Total
1,157
1,086
94%
Normal Abnormal
Figure 5. Analogue arterial wave tracing, normal
right side and abnormal left side.
of noninvasive diagnostic modalities like: Dop-
pler ultrasound, impedance, air, mercury and
strain gauge plethysmograph, 1-25 fibrinogen,
and radionuclide phlebography.
The strain gauge plethysmography (SPG), the
impedance plethysmograph (IPG), and the
Doppler venous ultrasound are probably the
most common tests used in this country for the
diagnosis of deep vein thrombosis (DVT). In
our laboratory, we have been using the strain
gauge plethysmography and sometimes 1-25
fibrinogen leg scanning.
Figure 6. The technique of the strain gauge
plethysmography (SPG) for the diagnosis of deep
vein thrombosis (DVT).
C
Tim* in ucondi
undti tingant line
T 0
Figure 7. Nomograph for measurement of maxi-
mum venous outflow in the diagnosis of deep vein
thrombosis (DVT).
Using strain gauge plethysmograph (Meda-
Sonics), the patient lies in a supine position
with the knee being tested flexed at 15 to 20
degrees. The leg is elevated with support under
the thigh and foot so that the calf is 20 to 25
centimeters above the examination table. The
strain gauge is positioned around the maximum
girth of the calf. The gauge is connected to the
plethysmograph, and a thigh pneumatic cuff is
connected to an automatic cuff inflator (Figure
6). The thigh cuff is inflated to 50 millimeters
Hg for a period of two minutes and then quickly
deflated. With the help of Nomagraph, the maxi-
mum venous outflow (MVO) can be calculated
(Figure 7).
It is desirable to repeat the procedure at least
one time. Results should be comparable. The
procedure should be repeated until consistent
results are obtained.
Diagnostic criteria for calf outflows (MVO):
41 ± 11 cc/min/100 cc tissue ( % min) —
within normal limits.
12 ± 8 cc/min/100 cc tissue (% min) —
compatible with DVT.
1-125 Fibrinogen Leg Scanning
Radioactive fibrinogen assesses the activity of
the thrombotic process. One hundred microcuries
of 1-25 labeled human fibrinogen is injected
intravenously. The circulating fibrinogen will
become incorporated into sites of active
thrombosis. The legs are scanned at multiple
sites along the course of the deep veins. The
TABLE 8
Comparison of Cases With Normal SPG
With the Venogram
Venogram
Number of Legs
Per Cent
Normal
Incompetent Perforators
(communicating veins)
58
5
90.6%)
)98.4%
7.8%)
Deep Vein Thrombosis
1
1.6%
Total
64
TABLE 9
Comparison of Cases With Positive SPG
With Venogram
Venogram N
umber of Legs
Per Cent
Deep vein thrombosis
25
60%
Incompetent perforators
(communicating veins)
15
36%
Normal
2
4%
Total
42
144
The West Virginia Medical Journal
radioactive counts relative to cardiac back-
ground activity are determined along each leg
and compared to adjacent areas on that leg and
to similar points on the opposite leg. A signifi-
cant increase in count, 15 to 20 per cent relative
to the same or opposite leg which persists on
succeeding days, is indicative of venous throm-
bosis.
Discussion
Five hundred, fifty patients had venous strain
gauge plethysmography testing from November,
1980, through March, 1982, at our laboratory.
These patients had symptoms and signs sugges-
tive of deep vein thrombosis. One hundred, six
limbs had venograms, and 136 had 1-25
fibrinogen leg scans, 94 with negative SPG and
42 with positive SPG. The results are analyzed
in Tables 8, 9, and 10.
The fallibility of clinical diagnosis in cases
of pulmonary emboli and venous thrombosis is
approximately 50 per cent. 9
Plethysmography involves the measurement of
limb hemodynamics on the basis of changes in
limb volume. 10 There are a variety of plethy-
smographic methods available which include
the mercury, water, air, impedance and strain
gauge plethysmography. All of these techniques
basically are designed to measure quantitatively
either the rate at which blood is drained from
the leg after a brief period of mechanically in-
duced total venous occlusion or the degree to
which the thrombosis interferes with the normal
changes in venous volume that accompany
respiration or pneumatic compression of the
thigh. Plethysmographic methods will not detect
an isolated clot in the hypograstric vein, deep
femoral veins or small muscular veins.
Barnes et al. have found the strain gauge
plethvsmograph to be the most useful technique
to quantitate the altered venous hemodynamics
in not only acute deep vein thrombosis but also
in the post-phlebitic syndrome and in primary
and secondary varicose veins. ' 8 If the SPG is
negative, exclusion of deep vein thrombosis can
usually be made: however, if the SPG is positive.
TABLE 10
Comparison of Cases With Positive SPG and
1-125 Fibrinogen Scan With Venogram
Venograms
Cases of DVT
Number of Cases
Incompetent
DVT Perforators
Normal
Per Cent
Positive SPG and
Leg Scan
24
23 1
0
96%
Positive SPG and
negative Leg Scan
18
2 14
2
11%
Total
42
either DVT or incompetent perforators (in-
competent communicating veins with no throm-
bosis) is likely to be present (96 per cent).
The 1-125 fibrinogen leg scan effectively aids
in differentiating those cases with positive SPG.
When a positive SPG is combined with positive
leg scan, the accuracy rate is 96 per cent true
positive (23 of 24 legs). If the SPG is positive
with negative leg scan, the diagnosis of in-
competent perforators is most likely to occur ( 14
of 18 legs, or 78 per cent).
In conclusion, the SPG is a reliable test in
excluding DVT (98 per cent). When combined
with fibrinogen leg scan, it has a reliability rate
of 96 per cent, but only 60 per cent are true
positives when SPG is done alone.
Summary
This study analyzes the results of over 5,000
patients studied in our noninvasive diagnostic
vascular laboratory in the last four years. These
included around 3,000 patients who had non-
invasive carotid testing, mainly oculoplethy-
smography ( OPG), with 1,080 arterial leg
Doppler (ALD) tests for peripheral vascular
occlusive disease (PVOD), 550 venous strain
gauge plethysmography (SPG) for deep vein
thrombosis (DVT), and about 1,000 other
miscellaneous tests.
We concluded that a combination of OPG/
Gee and real-time B-image scanning was the
best noninvasive testing for the diagnosis of
carotid artery stenosis. Arterial leg Doppler
testing was very satisfactory in the diagnosis of
peripheral vascular occlusive disease. The venous
strain gauge plethlysmograph was excellent in
excluding cases of deep vein thrombosis.
Acknowledgments
We wish to thank Gordon Gee, Supervisor of
Biomedical Photography, West Virginia Univer-
sity Medical Center, Morgantown, and Bill
Hogan, Graphic Arts Designer, Charleston Di-
vision, WVU Medical Center, for their coopera-
tion with illustrations used in this article.
References
1. AbuRahma AF, Boland J, Diethrich EB: Correla-
tion of the resting and exercise Doppler ankle/ arm index
to angiographic findings. Angiology 1980; 31:331-336.
2. AbuRahma AF, Diethrich EB: Diagnosis of carotid
arterial occlusive disease. Vase Surg 1980; 14:23-29.
3. AbuRahma AF, Diethrich EB: Doppler testing in
peripheral vascular occlusive disease. Surg Gynecol
Obstet 1980; 150:26-28.
4. AbuRahma AF, Diethrich EB: Doppler ultrasound
in evaluating the localization and severity of peripheral
vascular occlusive disease. South Med ] 1979; 72:1425-
1428.
July, 1983, Vol. 79, No. 7
145
5. AbuRahma AF, Diethrich EB: The yield and re-
liability of oculoplethysmography and carotid phono-
angiography in stroke screening and the diagnosis of
extracranial carotid occlusive disease. W Va Med J 1979;
75:254-260.
6. AbuRahma AF, Lawton WE Jr, Boland J, Diethrich
EB: Correlation of the resting and exercise Doppler
ankle/ arm index to the symptomatology and to the
angiographic findings, in: N oninvasive Assessment of the
Cardiovascular System, Wright-PSG, Inc, 1982.
7. Barnes RW, Collicott PE, Sumner DS et ah: Non-
invasive quantitation of venous hemodynamics in the
postphlebitic syndrome. Arch Surg 1973; 107:807.
8. Barnes RW, Ross EA, Strandness DE Jr.: Dif-
ferentiation of primary from secondary varicose veins by
Doppler ultrasound and strain gauge plethysmography.
Surg Gynecol Obstet 1975; 141:207.
9. Dalen JE, Dexter L: Pulmonary embolism. JAMA
1969; 207:1505.
10. Dohn K: Plethysmography during functional
states for investigation of the peripheral circulation, pro-
ceedings of the Second International Congress of Physics,
Copenhagen, 1957. Dansk Fysiurgisk Selskab, p 51.
11. Gee W, Oiler DW, Homer LD, Bailey CR: Simul-
taneous bilateral determination of the ophthalmic arteries.
Inves Ophthalmol Vis Set 1977; 16:86-89.
12. Kartchner MM, McRae LP, Crain V et ah: Oculo-
plethysmography: An adjunct to arteriography in the
diagnosis of extracranial carotid occlusive disease. Am J
Surg 1976; 132:728-738.
13. Malone JM, Bean B, Laguna J et al.: Diagnosis
of carotid artery stenosis. Ann Surg 1980; 191:347-354.
14. McDonald PT, Rich NM, Collins GJ et ah: Dop-
pler cerebrovascular examination, OPG and ocular pneu-
moplethysmography. Arch Surg 1978; 113:1341-1349.
15. Stegall HF, Rusfmier RF, Baker DW: A trans-
cutaneous blood velocity meter. J Appl Physiol 1966;
21:707-711.
16. Winsor T: The influence of arterial disease on
the systolic blood pressure gradients of the extremity.
Am J Med Sci 1950; 220:117.
17. Yao JST, Bergan TJ: Application of ultrasound to
arterial and venous diagnosis. Surg Clin North Am 1974;
54:23-27.
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Medical Journal, Box 1031, Charleston, W. Va. 25324.
146
The West Virginia Medical Journal
Tuberculosis After Jejunoileal Bypass Surgery*
LEEMAN P. MAXWELL. M. D.
Fellow in Cardiology , Department of Medicine, West
Virginia University School of Medicine, Morgantown
RASHIDA A. KHAKOO, M. D.
Associate Professor of Medicine, WVU School of
Medicine, Morgantown
EDWIN J. MORGAN, M. D.
Professor of Medicine, WVU School of Medicine,
Morgantown
A young man underwent jejunoileal bypass
surgery for morbid obesity. He later developed
disseminated tuberculosis. There is increased
risk of tuberculosis following this type of surgery
as tvell as post-gastrectomy. These patients
should be screened for tuberculosis prior to sur-
gery and folloived closely post-operatively for this
complication.
Case Report
A white male in his early thirties underwent
greater than 90-per cent jejunoileal bypass for
morbid obesity in 1979. He did well, losing ap-
proximately 200 pounds ( over 50 per cent of his
pre-operative weight ) . About two years later,
he noted weakness, easy fatigability, generalized
arthralgias and myalgias, with nightly fevers,
chills and sweats. He also unintentionally began
to lose more weight. His surgeon evaluated him
for lymphoma when a mediastinal mass was noted
on chest x-ray. A lymphangiogram and abdom-
inal CT scan showed diffuse lymphadenopathy.
Sternotomy demonstrated a benign thymic cyst
with numerous noncaseating granulomas. This
tissue was not cultured. A positive purified pro-
tein derivative (PPDl was overlooked.
Approximately one year ago, the patient was
admitted to West Virginia University Hospital
in moderate distress and malnourished. An inter-
mediate-strength PPD produced 25 mm of in-
duration at 24 hours. The mediastinal mass as
well as a right apical infitrate were seen on chest
roentgenogram (Figure). Axillary lymph node
biopsy demonstrated caseating granulomas. Cul-
tures from both the sputum and lymph node grew
Mycobacterium tuberculosis. Liver, urine and
bone marrow cultures were negative.
The patient’s symptoms resolved and he began
to gain weight after treatment with isonicotine
hydrazine ( INH ) , ethambutol. and rifampin.
Serial serum drug levels documented adequate
therapy (Table).
“This paper was written while Doctor Maxwell was a
resident in medicine. West Virginia University School of
Medicine, Morgantown.
Discussion
Eighteen patients with tuberculosis compli-
cating intestinal bypass surgery were reported in
the literature between 1969 and 1980. This rep-
resents an incidence of one to four per cent, de-
pending on the study, 1 and a greater than 63-
fold increase (estimated) in the risk of tuber-
culosis over the general population. 2
These patients more often present with extra-
pulmonary tuberculosis, most commonly with
lymph node involvement. The symptom com-
plex of accelerated weight loss, lymphadeno-
pathy, and unexplained fever suggests tuberculo-
sis. The average time to onset of symptoms fol-
lowing bypass is 16 months. 3 This length of time
Figure. Left subclavian lymph nodes are seen
with lymphangiogram contrast dye. The mediasti-
num is wide. The right apex and partachael area
demonstrate pulmonary involvement.
TABLE
Serum Levels of Oral Antituberculosis Drugs
DRUG INH Ethambutol Rifampin
DOSE 400mg 30mg/kg 1200mg
THERAPEUTIC 0.4-4.0 3-12 10-40
RANGE (mcg/ml)
TIME SERUM CONCENTRATION (mcg/ml)
1 hr
6.5
—
2 hrs
—
7.55
15.4
3 hrs
—
—
11.6
4 hrs
5.2
3.17
6.2
July, 1983, Vol. 79, No. 7
147
is usually coincident with the phase of rapid
weight loss which occurs post-operatively . 4
The association of pulmonary tuberculosis
after gastrectomy with malabsorption has been
well-documented . 2,3 Malnutrition with weight
loss and its sequelae of immunosuppression is
considered an important factor in the increased
susceptibility to tuberculosis . 2 Lymphocyte
transformation in the presence of specific antigen
in intestinal bypass patients with tuberculosis
gave positive but less energetic responses than
normal controls . 2
These data suggest that these patients cannot
defend themselves normally against tuberculosis,
especially during the period of rapid weight loss.
The other major problem in these patients is
assuring adequate therapy because of decreased
absorptive surface and rapid transit. Ethambutol
is absorbed from the stomach and proximal
jejunum. Rifampin participates in an entero-
hepatic circulation with proximal absorption in
the stomach with biliary excretion and jejunal
reabsorption. Therefore, serum levels of these
drugs should be done to document adequate
therapy . 2 Our patient is only the third patient re-
ported to have documented adequacy of treat-
ment with serum drug levels.
Yu 3 recommends that all patients being con-
sidered for this surgery undergo intermediate
PPD prior to surgery. If positive and no disease
is found, he recommends one year of treatment
with INH. as is done with post-gastrectomy pa-
tients.
These patients illustrate the need to be aware
of the increased risk of tuberculosis following
jejunoileal bypass surgery. They should receive
INH prophylaxsis for one year following surgery
if the PPD is positive. Finally, serum drug levels
are necessary to ensure adequate therapy.
Acknowledgements
Lederle Laboratories and Merrell Dow Phar-
maceuticals for performing the drug assays.
References
1. Doldi SB: Tuberculosis after intestinal bypass for
morbid obesity, Int Surg 1980; 65:131-134.
2. Bruce RM, Wise L: Tuberculosis after jejunoileal
bypass for obesity. Ann Intern Med 1977; 87:574-576.
3. Yu VL: Onset of tuberculosis after intestinal by-
pass surgery for obesity. Arch Surg 1977; 112:1235-1237.
4. Bray GA, Barry RE, Benfield JR, Castelnuevo-
Tedesco P, Drenick EJ, Passaro E: Intestinal bypass
operation as a treatment for obesity. Ann Intern Med
1976; 85:97-109.
Conservative Treatment Recommended
A large-scale study by surgeons and physicians at Houston’s M.D. Anderson Hos-
pital suggests that conservative surgery and irradiation are viable alternatives to
radical mastectomy for selected patients with early breast cancer.
Writing in a recent issue of Archives of Surgery, Marvin M. Romsdahl, M.D., Ph.D.,
and colleagues report that 922 patients were followed from 1955 through 1979 in a
study that compared conservation surgery and irradiation with radical or modified
radical mastectomy in the treatment of minimal, stage I and stage II breast cancer.
“Disease-free survival rates at five and 10 years for patients having radical mas-
tectomy or conservation surgery with irradiation are similar,” the researchers say.
148
The West Virginia Medical Journal
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July, 1983, Vol. 79, No. 7
149
*Jke President
2J
THE ROLE OF OUR ORGANIZATION
S ometimes in the stress of day-to-day medical
practice, amid the complexities of modern-
day life, we tend to lose track of the original
goals and purposes of our organization. Indeed,
some of us may have forgotten or never have
known of them. It is refreshing and enlighten-
ing now and again to look back at our stated
purposes. To this end I quote the pertinent
section of our constitution.
Article II, Section 1 of the Constitution of the
West Virginia State Medical Association states
“the purposes of this association shall be to
federate and bring into one compact organiza-
tion the entire medical profession of the state of
West Virginia, and to unite similar associations
or societies of other states to form the American
Medical Association; to extend medical knowl-
edge and advance medical science; to promote
the public health; to elevate the standards of
medical education; to secure the enactment and
enforcement of just medical laws; to promote
the general welfare of physicians; and to en-
lighten and direct public opinion in regard to
the problems of state medicine so that the pro-
fession shall become more capable and honor-
able within itself, and more useful to the public
in the prevention and cure of disease and in
prolonging life and adding comfort thereto.”
At the risk of “preaching to those already in
church,” I would like to reflect for a bit on some
of the stated purposes of our organization — “to
bring into one compact organization the entire
medical profession of the state of West Vir-
ginia.” This means membership. It is important
to bring all the practitioners of our profession
into the membership of our Association so that
we may indeed speak as one united voice. Our
Association, like any other, constantly gains and
loses members. New practitioners move into
the state; others leave the state or retire. It is
vitally important that we encourage newer
practitioners and other non-members to unite
with us in membership so that our Association
may fulfill its purpose of representing the entire
medical profession of West Virginia.
“To extend medical knowledge and advance
medical science.” “To promote the public
health.” “To elevate the standards of medical
education and to secure the enactment and en-
forcement of just medical laws.” Without an
active and involved, representative Association
to achieve these goals, one individual practi-
tioner has but limited resources to use in an at-
tempt “to promote the general welfare of physi-
cians and to enlighten and direct public opinion
— so that the profession shall become more use-
ful to the public in the prevention and cure of
disease and in prolonging life and adding com-
fort thereto.”
Without the resources of our Association, the
individual would find this an almost insur-
mountable task, but, paradoxically, the Associa-
tion cannot survive without the resources and
actions of individual members. There is a sym-
biosis between the organization and the actions
of the individuals within that organization. One
cannot survive without the other. Accordingly,
as individual members, we must continue to at-
tract other individuals to the organization to
increase its strength and resources for our
mutual benefit.
We members cannot rely only on our office
staff to carry out all the activities needed to pro-
mote the goals of our Association. The re-
sources of our office are many and are there for
the members to use, but our six staff members
cannot respond to inquiries from the press,
legislature, and others, publish The Journal, in-
fluence all the necessary lawmakers, run the in-
surance program, schedule and operate the
CME activities and meetings, etc., without help
from us, the members. They can provide the
resources but it is up to us to provide the action.
If we do not, our goals will not be met. I look
forward to seeing each of you at our Annual
Meeting to provide that action!
Harry Shannon, M. D., President
West Virginia State Medical Association
150
The West Virginia Medical Journal
The Vest Virginia Hedical Journal
Editorials
The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or
in communications submitted to this Journal for publication. The author shall be held entirely responsible.
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State
Medical Association.
Despite the furor, confusion and complexity
of modern living, Gerald C. Kempthorne, M. D.,
President of the State Medical Society of
W isconsin, always returns to one fundamental
premise. Despite the changing atmosphere sur-
rounding the practice of Medicine, he recently
noted, “I find physicians are continuing to do
what they have always done — practice quality
medicine for the patients they are committed to
serve.”
“Certainly, the delivery systems have changed
dramatically,” Doctor Kempthorne wrote in the
Wisconsin Medical Journal. “However, I have
seen no diminution in the
QUALITY physician’s fervor in continu-
COMMITMENT ing the role of patient’s advo-
cate. In view of the rapidly
changing scene, the one solid profession behind
the welfare of the patient is the House of
Medicine. Schemes and scenarios may come and
go, but when the dust settles, the physician will
he there, as usual, caring for his or her patient."
The Wisconsin President has emphasized, con-
sistent with general thinking reflected in con-
tinuing medical education programs and other-
wise, that keeping up is an important part of the
profession. There is, he said, no other health
caring profession which can demonstrate more
effectively the advances in human health care
than what we have witnessed in Medicine.
“We are now able to diagnose serious illness
without dangerous invasion of the body,” Doctor
Kempthorne observed. “There is hardly a con-
dition of the human body we cannot treat in one
manner or another with varying degrees of suc-
cess. People want expert medical care, and it
has been laid at the doorstep of every patient.”
“Essentially, most people want freedom from
disease, and long life,” he continued. “Is that
an unreasonable aspiration? Only recently have
people begun to do their part with efforts at
wellness and prevention of disease. Until the
long-term benefit from that activity arrives,
society still will be faced with the need to treat
disease and illness.”
Touching on a theme common everywhere,
and getting varying degrees of legislative and
other attention. Doctor Kempthorne noted that
“virtually no obstacles stood in the way of
achieving the long, good life until it was finally
recognized that it really does cost money to
underwrite such an ambitious endeavor." He
added :
“Now, the realization is upon us that optimal
medical care is costly. Who wants to say that
we should de-emphasize the importance of a
long, healthy life? If it takes 10 per cent of the
gross national product in order to assure that
quality of life, is that had, even if we could be
more efficient in the system?”
Doctor Kempthorne also stressed that to
malign the hospital system and physicians in
America as the culprits of the escalating cost
scenario is far too simple. The current preoccu-
pation with health care costs won’t mean much
unless society at large decides to take an active
role.
Now. let’s let Doctor Kempthorne take it from
here against a background of some of the think-
ing and legislative activity which recently has
come to the front in West Virginia:
“If health care is to be optimal in all circum-
stances, then there will be a substantial price tag
attached, despite all efforts at economizing. Will
someone have the bravery to suggest that ordi-
nary or adequate care is good enough? If we
can't afford optimal care, who will suggest ration-
ing? Can you imagine writing guidelines for
limits on medical care because of the cost?
Currently, it is fashionable to ‘penalize’ the poor
by requesting a copayment for services after
giving them a medical card because they couldn’t
afford medical care in the first place.
“Until we can ‘cure’ the insatiable appetite for
optimal health care by all of us, we are truly
facing an enigma. We (meaning our social
order ) have virtually encouraged all of our
citizens to seek optimal care in the past. Now
July, 1983, Vol. 79, No. 7
151
we are ‘hinting’ that we can't afford it, and we
are spending a lot of time and effort to find
the cause of the problem we created in the first
place.
“The current ‘cost of health care’ is much like
a red ink jigsaw puzzle without form. There are
so many parts in the faceless form that it makes
it difficult and depressing to try to put it all
together. Experts and ideas will come and go to
solve the amorphous riddle. Whatever set of
principles finally evolves, the medical profession
will remain at the ‘bedside’ of the patient and
never abandon his or her calling, despite the cry
from the outside."
A heartening trend in patient care continues
in West Virginia, and in fact appears to be
picking up still more momentum. Fifteen of the
20 family physicians completing their residency
training this summer are remaining in the state.
That’s 75 per cent, about the ongoing figure for
that particular program.
Increased numbers of West Virginia Uni-
versity School of Medicine graduates are practic-
ing here after completing their
NEW training. That percentage is near
RESOURCES 50 since 1974. Early indications
are that the same general pattern
will develop with graduates from the Marshall
LIniversity School of Medicine.
In addition. West Virginians who have been
practicing or in training elsewhere are coming
back in noticeable numbers. They are return-
ing from such points as South Carolina and
Texas, and going to such counties as Summers
and Pocahontas.
This is the time of the year in which, across
the nation, many young doctors complete resi-
dencies and enter into practice. They begin
a challenging and fascinating new phase of their
careers — and one which also is certain to bring
some frustration and adjustment problems.
We trust, in West Virginia, that our medical
communities will welcome these new colleagues,
and stand ready to assist and counsel them. We
need their knowledge and skills, and their move-
ment to rural and so-called physician shortage
areas, in particular, must be further encouraged.
Clearly, some of the young doctors will find
that their training, heavily weighted in scientific
knowledge, has left something to be desired in
the social, economic, legal and political aspects
of medical practice, and of the complex health
care system in which they will work.
They will be faced with the specific challenge
of always trying to do what is best for their
patients in a very cost-sensitive health care en-
vironment.
The new doctors will find society confused
about what to do about health care and its rising
cost. Society wants more health care for more
people and equal access for all to high quality
care, but is balking at the expense.
It’s important for all physicians, old and new,
never to forget that their primary obligation is
the historic responsibility of doctor to patient.
This always must come ahead of any business
or corporate obligations.
The Missouri State Medical Association,
through its Journal, recently reminded its mem-
bers that most groups appearing before the
Missouri General Assembly are “single issue"
in nature.
These groups, despite small numbers, organize
very effective campaigns to gain
SINGLE ISSUE approval of their particular
objective. They work hard to
make personal contact with each representative
and senator.
Physicians, meanwhile, apparently have come
to believe that someone else will take care of
their interests in this bothersome (legislative)
area — and they are wrong, the Missouri Journal
stressed.
Legislators, it added, are going to vote accord-
ing to the wishes of the constituents who contact
them. If physicians choose not to be heard, they
won’t be!
Does all this sound familiar? It should. It
simply echoes what the West Virginia State
Medical Association leadership has been saying
over and over again. Instead of “single issue”
we've used the words “single shot." But the les-
son is the same.
While one particular group is working on one
bill, an organization such as the Medical Associa-
tion will be monitoring or dealing to some degree
with 100 or more. Staff and other resources
accordingly are thinly spread.
Without more and more physician interest and
input, concerns of this Association and the
patients for whom it is the advocate are in
trouble. And as they say in Missouri, if physi-
cians choose not to be heard, they won’t be.
152
Thf. West Virginia Medical Journal
GENERAL NEWS
Convention Symposium To Eye
Cardiovascular Disease
Cardiovascular surgery and cardiac arrhyth-
mias will be among subjects discussed in a
“Symposium on Cardiovascular Diseases” during
the 116th Annual Meeting of the State Medical
Association.
The speakers on the above two subjects, it
was announced by the Program Committee, will
be Drs. John C. Alexander, Jr., of Morgantown,
whose topic will be “Cardiovascular Surgery —
John C. Alexander, Jr., M. D. Stafford G. Warren, M. D.
An Update;” and Stafford G. Warren, Charleston
cardiologist, “New Developments in the Man-
agement of Cardiac Arrhythmias.”
The symposium, which also will include a
paper on congestive heart failure, will constitute
the second general scientific session of the con-
vention Saturday morning, August 27.
The Annual Meeting will be held August 25-27
at the Greenbrier in White Sulphur Springs.
Doctor Alexander is Associate Professor of
Surgery and Chief, Section of Cardiothoracic
Surgery at the West Virginia University School
of Medicine.
Doctor Warren is Clinical Professor of Medi-
cine at WVU Charleston Division.
The Annual Meeting will open with a pre-
convention session of the Association’s Council
and the first session of the House of Delegates
on Thursday morning and afternoon, August 25:
and end with the second and final House session
and reception for Association members and
guests Saturday afternoon, and a dinner that
evening I see story on page 154 for details).
Doctor Adkins to be Installed
At the final House session on Saturday after-
noon, Dr. Carl R. Adkins of Fayetteville will
he installed as the Association’s 1983-84 Presi-
dent to succeed Dr. Harry Shannon of Parkers-
burg.
Dr. Frank J. Jirka, Jr., President of the
American Medical Association, as announced
previously, will address the first House session
on Thursday. He is from Barrington, Illinois.
Dr. Samuel P. Asper of Philadelphia, also as
announced, will deliver the keynote Thomas L.
Harris address during opening exercises Friday
morning preceding the first general scientific ses-
sion. Doctor Asper, who is President of the
Educational Commission for Foreign Medical
Graduates, will speak on “Strengths and Weak-
nesses of the U. S. Role in International Medi-
cine.”
First Scientific Session
Friday morning speakers and topics for the
first general scientific session, a “Symposium on
Sexually Transmitted Diseases,” will be:
“Syphilis and Gonococcal Infections” — Dr.
Edmund C. Tramont (colonel, U. S. Army Medi-
cal Corps), Chief, Infectious Diseases, Depart-
ment of Bacterial Diseases, Walter Reed Army
Institute of Research, Washington, D.C.; and
Associate Professor of Medicine and Coordi-
nator (Chief), Division of Infectious Diseases,
Uniformed Services University of the Health
Sciences Medical School. Bethesda. Maryland:
“Non-Luetic, Non-Gonococcal Venereal Dis-
eases” — Dr. Lee P. Van Voris, Chief, Infectious
Diseases, and Epidemiologist at Hamot Hospital,
Erie. Pennsylvania I formerly Associate Professor
of Medicine, Marshall University School of
Medicine I ;
“Transmissible Diseases of the Gay Patient"
— Dr. George J. Pazin, Associate Professor of
Medicine, University of Pittsburgh; and “Sexual
Mores in the 1980s” — Dr. Jack L. Summers,
Chairman, Department of Urology, Akron
(Ohio) City Hospital, and Professor, Depart -
July, 1983, Vol. 79, No. 7
153
ment of Urology, Northeastern Ohio Universities
College of Medicine, Akron.
In addition to the House and general sessions,
the Annual Meeting agenda will include break-
fast, luncheon and other programs arranged by
specialty societies and sections, many of which
also will provide scientific discussions.
Scientific Exhibits
Scientific exhibits, again to be housed in
Eisenhower Hall, will be open from 1 to 5 P. M.
on Thursday, and from 8:30 A. M. to noon on
Friday and Saturday. The exhibits will be listed
in the August issue of The Journal. In order to
provide convention registrants with ample oppor-
tunity to visit the exhibits, coffee breaks for that
purpose have been scheduled during the general
scientific session Friday and Saturday mornings.
The scientific sessions will he held in the theater,
which adjoins Eisenhower Hall.
Doctor Alexander came to WVU in 1982 from
Cornell University, where he was Assistant Pro-
fessor of Surgery.
A native of Durham, North Carolina, he was
graduated from Duke University, and received
his M. D. degree in 1971 from the University’s
School of Medicine. He was the recipient of an
Early Internship at Duke in 1971-72, completing
his residency there and at the Surgery Branch,
National Cancer Institute, National Institutes of
Health, Bethesda, Maryland.
Doctor Alexander was a Teaching Scholar at
Duke in 1979-80 before going to Cornell.
University of Rochester Graduate
Doctor Warren is certified in internal medicine
and cardiology, and is a Fellow of the American
College of Cardiology. He was graduated from
Davidson ( North Carolina ) College, did a year
of graduate work at Wesleyan University in
Middletown, Connecticut, and then entered the
University of Rochester School of Medicine,
receiving his M. D. degree in 1969.
He interned at the University Hospital of
Cleveland, and completed postgraduate studies
there and at Duke University.
Doctor Warren is a member of the active staff
at Charleston Area Medical Center (CAMC),
and was the 1975 recipient of a research grant
from Medical Associates (CAMC) for a CPK
isoenzyme study.
He is the author or co-author of some 13
scientific publications.
The Auxiliary to the State Medical Associa-
tion, with Mrs. Richard S. Kerr of Morgantown
the current President, as usual will hold its
meeting in conjunction with that of the Associa-
tion.
1983 Program Committee
Members of the 1983 Program Committee
are David Z. Morgan, M. D., Morgantown,
Chairman; Doctor Adkins; Jean P. Cavender,
M. D., Charleston; Michael J. Lewis, M. D.. St.
Marys; Kenneth Scher, M. D., Huntington, and
Roland J. Weisser, Jr., M. D., Morgantown.
The official convention program, and infor-
mation concerning remaining speakers and other
details will be provided in the August issue of
The Journal.
Saturday Convention Dinner
Added To Schedule
As noted in the June issue of The Journal,
the Medical Association’s Annual Meeting
Program at the Greenbrier will be enhanced
this year by a black-tie dinner to honor out-
going and new leaders of the Association and
Auxiliary.
This dinner, a “by-ticket only” innovation,
is scheduled for Saturday evening, August 27.
It will be held in Chesapeake Hall and will be
the convention’s last event, following the
second and final House of Delegates meeting.
The dinner will enable the Association and
Auxiliary leadership to offer comments, in a
largely informal style, they feel pertinent as to
the organizations’ activities, objectives and the
like. Invited guests will include the Presidents
and spouses of the American Medical Associa-
tion, and neighboring states represented each
year.
It might be necessary for some of those who
have made their hotel reservations to review
them in the light of plans they might revise
to attend the Saturday dinner.
Current plans call for dinner tickets to be
on sale at the Association and Auxiliary regis-
tration desks, beginning on Thursday morn-
ing, August 25. It will be necessary to pro-
vide the Greenbrier with an attendance
guarantee by late on Friday, August 26.
At this writing, planning for the dinner is
continuing, and the membership will be kept
advised as other details fall into place. Mean-
while, if any physicians already have plans to
attend, and desire to advise the Association
office, P. 0. Box 1031, Charleston 25324,
that advance information would be helpful.
154
The West Virginia Medical Journal
Continuing Education
Activities
Here are the continuing medical education
activities listed primarily by the West Virginia
University School of Medicine for part of
1983, as compiled by Dr. Robert L. Smith,
Assistant Dean for Continuing Education, and
J. Zeb Wright, Ph. D., Coordinator, Con-
tinuing Education, Department of Community
Medicine, Charleston Division. The schedule is
presented as a convenience for physicians in plan-
ning their continuing education program. (Other
national, state and district medical meetings are
listed in the Medical Meetings Department of
The Journal. )
The program is tentative and subject to
change. It should be noted that weekly confer-
ences also are held on the Morgantown, Charles-
ton and Wheeling campuses. Further information
about these may be obtained from: Division of
Continuing Education. WVU Medical Center,
3110 MacCorkle Avenue, S. E., Charleston
25304: Office of Continuing Medical Education.
WVU Medical Center, Morgantown 26506; or
Office of Continuing Medical Education, Wheel-
ing Division. WVU School of Medicine, Ohio
Valley Medical Center. 2000 Eofl Street. Wheel-
ing 26003.
Sept. 3. Morgantown, Treatment Options in
Arthritis
Sept. 9-10, Morgantown, Ob/Gyn Teaching
Days
Sept. 14, Charleston. Advances in Hypertension
Regularly Scheduled Continuing
Education Outreach Programs from
WVU Medical Center/
Charleston Division
Buckhannon . St. Joseph’s Hospital, first-floor
cafeteria, 3rd Thursday. 7-9 P. M. — July
( summer break ) .
Cabin Creek, Cabin Creek Medical Center,
Dawes. 2nd Wednesday, 8-10 A. M. — July 13,
“Headaches,” A. L. Poffenbarger. M. D.
Cassaway, Braxton Co. Memorial Hospital. 1st
Wednesday, 7-9 P. M. — July 6, “The Phar-
macology of Hypertension Management,”
Stephen Grubb, M. D.
Aug. 3, “Diagnosis of Pulmonary Disorders,”
Dominic Gaziano, M. D.
Madison, 2nd floor, Lick Creek Social Services
Bldg., 2nd Tuesday, 7-9 P. M. — July 12,
“Approach to the Peripheral Vascular Pa-
tient,” Ali F. AbuRahma, M. D.
Oak Hill, Oak Hill High School (Oyler Exit, N
19) 4th Tuesday, 7-9 P. M. — July (summer
break ) .
Welch, Stevens Clinic Hospital, 3rd Wednesday,
12 Noon-2 P. M. — July (summer break).
Whitesville, Raleigh-Boone Medical Center, 4th
Wednesday, 11 A.M.-l P.M. — July-August
(summer break)
Williamson, Appalachian Power Auditorium, 1st
Thursday, 6:30-8:30 P. M. — July (summer
break I .
Alzheimer’s Disease Autopsies
Needed, Researcher Urges
A California pathologist calls for more autop-
sies of Alzheimer's disease victims to assist
researchers investigating this puzzling and dev-
astating disorder.
“Despite its past anonymity, Alzheimer’s dis-
ease is a killer that strikes over 1.5 million
Americans and causes about 50 per cent of all
nursing home admissions, at a staggering annual
cost of $20 billion,” said George G. Glenner,
M. D., in an editorial in a recent issue of
Archives of Pathology and Laboratory Medicine.
The University of California, San Diego, re-
searcher said the National Alzheimer’s Disease
Brain Bank at his institution emphasizes the need
for autopsies to obtain adequate material for
research investigations on the disease, as well as
to offer families an accurate diagnosis. Since a
genetic component for the disease has been sug-
gested, families can gain helpful information
through accurate diagnosis of the cause of death
of aged parents who had symptoms resembling
Alzheimer’s disease.
Thyroidectomy Speaker
Dr. Romeo Y. Lim of Charleston spoke on
“Emergency Thyroidectomy for Tracheal Ob-
struction" at the New York University “Otolaryn-
gology Update ’83” in June in New York City.
Doctor Lim is Clinical Associate Professor of
Otolaryngology — Head and Neck Surgery at
West Virginia University, and an active staff
member of the Eye and Ear Clinic of Charles-
ton.
July, 1983, Vol. 79, No. 7
155
Reference Manual Offered
By Cancer Society
Cancer Manual, a cancer reference text, now
is available from the West Virginia Division of
the American Cancer Society.
The 444-page manual provides a fundamental-
ly pragmatic approach to the problems of pa-
tients with specific cancers. It also includes many
contemporary issues such as those dealing with
psychosocial aspects, sexuality, nutrition, hospice
concepts, and the role of nurses and social work-
ers.
As such, the Cancer Society commented, this
book should be of interest to practicing physi-
cians, interns, residents, medical students, nurses,
and all others involved in cancer care. It can be
used as a desk-top reference for history and
physical examination techniques, diagnostic prin-
Review A Book
The following books have been received by the
Headquarters Office of the State Medical Associa-
tion. Medical readers interested in reviewing hny
of these volumes should address their requests to
Editor, The West Virginia Medical Journal. Post
Office Box 1031, Charleston 25324. We shall he
happy to send the hooks to you, and you may
keep them for your personal libraries after sub-
mitting to The Journal a review for publication.
Current Medical Diagnosis and Treatment ,
1083, edited by Marcus A. Krupp, M. D.; and
Milton J. Chatton, M. D. 1130 pages. Price $24.
Lange Medical Publications, Los Altos, Cali-
fornia 94022. 1983.
General Ophthalmology, 10th Edition, by
Daniel Vaughan, M. D.; and Taylor Asbury,
M. D. 407 pages. Price $17. Lange Medical
Publications, Los Altos, California 94022.
1983.
Neuroanatomy: An Atlas of Structures, Sec-
tions, and Systems, by Duane E. Haines, Ph.D.,
Professor of Anatomy, West Virginia LIniversity
School of Medicine, Morgantown. 212 pages.
Price $19.50. Urban & Schwarzenberg Medical
Publishers, 7 East Redwood Street, Baltimore,
Maryland 21202. 1983.
Review of Medical Physiology, 11th Edition,
by William E. Ganong, M. D. 643 pages. Price
$20. Lange Medical Publications, Los Altos,
California 94022. 1983.
ciples, and epidemiology of cancer sites. In-
formation on pathology, the various treatment
modalities, and rehabilitation techniques also are
covered.
The book can be obtained by sending a check
for $4, payable to American Cancer Society,
West Virginia Division, Inc., to the Society at
240 Capitol Street - Suite 100, Charleston 25301.
Doctor Santrock Elected
WVU Alumni Head
Dr. David A. Santrock of Charleston recently
was elected the 82nd President of the West Vir-
ginia University Alumni Association during 1983
alumni/commencement weekend activities.
Doctor Santrock, an orthopedic surgeon, re-
ceived a B. S. degree in 1963 from WVU, and
his M. D. degree in 1967 from the University’s
School of Medicine. He has been a member of
the Alumni Association Executive Council since
1980.
Elected Vice President was Lucy Bowers
Eilson, 1950, of Beckley, civic and alumni leader.
Dr. Stanley J. Kandzari of Morgantown, first row,
left, was installed as President of the West Virginia
Chapter, American College of Surgeons at its spring
meeting held at the Greenbrier. Other officers
shown are, from left, front row, Sharon Bartholo-
mew, Morgantown, Executive Secretary, and Drs.
Catalino B. Mendoza, Jr„ Clarksburg, President
Elect, and William R. McCune, Martinsburg, Coun-
cilor; second row, Drs. Roger E. King, Morgantown,
First Vice President, and William E. Gilmore, Park-
ersburg, Councilor; third row, Drs. Billie M. Atkin-
son, Parkersburg, and James A. Coil, Jr„ Hunting-
ton, Councilors. Dr. Herbert G. Dickie, Jr„ of
Wheeling is Governor, and Dr. Alvin L. Watne of
Morgantown, Secretary-Treasurer.
156
The West Virginia Medical Journal
1983 Scholarship Winners
Named By Committee
The West Virginia State Medical Association
has awarded to another four state students four-
year scholarships to the West Virginia University
and Marshall University Schools of Medicine.
Each scholarship is worth $1,500 annually, or
$6,000 total.
Here are the 1983 selections of the Associa-
tion’s Committee on Medical Scholarships, as
announced by the Committee Chairman. John
Mark Moore, M. D., of Wheeling, after an annual
Committee meeting early in June in Bridgeport:
William M. Skeens of Huntington, who will
enter MU School of Medicine this fall; and Debra
Sue Hinzman of Harrisville, Susan Marie Sypolt
of Terra Alta, and John L. Stanley of Fayette-
ville, who will be first-year students at the WVU
School of Medicine.
Married and the father of two children, Skeens
received a B. S. degree in chemistry at MU this
past spring. He is the son of Mr. and Mrs. Wil-
liam C. Skeens, Jr., of Barboursville.
Biology Degree
Miss Hinzman. the daughter of Mr. and Mrs.
Luther H. Hinzman of Harrisville, was graduated
this spring from WVU with a B. S. degree in
biology.
Miss Sypolt received a B. A. degree in chem-
istry this spring at WVU. She is the daughter of
Mr. and Mrs. Robert Sypolt of Terra Alta.
Stanley is the son of Mr. and Mrs. Albert L.
Stanley of Fayetteville. He earned a B. S. de-
gree in biology in December, 1982. from West
Virginia Wesleyan.
The new awards bring to 68 the number of
scholarships granted by the Medical Associa-
tion since its program began in 1958. One
scholarship was granted annually until 1962,
A
Debra Sue Hinzman
William M. Skeens
Susan Marie Sypolt John L. Stanley
when the number was increased to two. In 1974,
the Association began awarding four scholarships
annually.
Financial need is the major factor considered
by the Committee on Medical Scholarships.
Under provisions of agreements they sign,
scholarship recipients must agree to practice in
West Virginia for four years following gradua-
tion and completion of postgraduate training
and military obligations.
Over the years, about 75 per cent of the
scholarship recipients who have completed their
training have entered practice in West Virginia,
a result in line with the program objective en-
couraging additional young physicians to estab-
lish careers here.
Other members of the Committee on Medical
Scholarships are Drs. R. L. Chamberlain of
Buckhannon, Marshall J. Carper of South
Charleston. Robert D. Hess of Clarksburg,
Thomas J. Holbrook of Huntington, James T.
Hughes of Ripley, Kenneth G. MacDonald. Sr.,
of Charleston. William L. Mossburg of Fairmont,
an earlier scholarship recipient, and David Z.
Morgan of Morgantown.
Scholars Program Recipient
Dr. Eric Sawitz of the Marshall University
School of Medicine is one of 20 physicians
chosen this year for the Robert Wood Johnson
Foundation Clinical Scholars Program. The
program began July 1.
He will spend two years studying health com-
munications and medical computing at Stanford
University and the University of California at
San Francisco. He will receive a complete
scholarship plus a stipend for his study and re-
search.
July, 1983, Vol. 79, No. 7
157
Results In Radial Keratotomy
Study Reported Good
A first prospective evaluation of radial kera-
totomy reports good short-term results for the
new operative procedure aimed at correcting
myopia.
Radial keratotomy is a surgical procedure in
which a series of incisions is made in the cornea
from the outer edge toward the center in spoke-
like fashion. It is done to correct an error of
refraction that causes rays of light entering the
eye to be brought to a focus in front of instead
of on the retina.
"Although the predictability of radial kera-
totomy is controversial, this study has shown that
radial keratotomy can be effective for reducing
myopia over a range of approximately 10 di-
opters,” report Peter N. Arrowsmith. M. D.. of
Nashville’s Parkside Surgery Center, and col-
leagues in a recent issue of Archives of Ophthal-
mology.
Caution in U. S.
The researchers point out that ophthalmolo-
gists have been cautious in judging the safety and
efficacy of radial keratotomy since its introduc-
tion in the United States in 1978. Opinions about
the procedure have ranged from mild endorse-
ment to confidence about its effectiveness in re-
ducing myopia and in its predictability.
"We report the results of one carefully per-
formed and monitored prospective evaluation of
radial keratotomy,” the researchers say. “The
emphasis of this report is on short-term efficacy
and safety.”
The study was conducted consecutively on
156 eyes of 101 patients. Before surgery, mean
spherical equivalent was -5.0 diopters, and un-
corrected distance acuity was 20/200 or worse
in 96 per cent of the eyes.
Six-Month Results
Six months after surgery, distance acuity was
20/20 in 43 per cent and 20/40 or better in 73
per cent of the eyes. The mean change in
spherical equivalent was +4.8 diopters.
“Visual acuity and refractive results were best
for eyes in which preoperative myopia was less
than 3.0 diopters, the researchers say. “In these
eyes, 92 per cent achieved 20/40 or better un-
corrected distance acuity six months after sur-
gery, and 61 per cent had 20/20 acuity or bet-
ter.”
Medical Meetings
July 31-Aug. 4 — National Spinal Cord Injury Assoc.,
Chicago.
Aug. 1-3 — International Society for Sexually Trans-
mitted Disease Research, Seattle.
Aug. 1-5 — -Am. Venereal Disease. Seattle.
Aug. 22-24 — Spinal Cord Regeneration & Recent De-
velopments (Am. Paraplegia Society), Las
Vegas.
Aug. 25-27 — 116th Annual Meeting, W. Va. State
Medical Assn., White Sulphur Springs.
Sept. 7-10 — Peripheral Vascular Disease Symposium
(Saint Anthony Hospital), Columbus, OH.
Sept. 29-Oct. 1 — Am. Assoc, for the Surgery of
Trauma.
Sept. 29-Oct. 2 — Am. Society of Internal Medicine,
San Francisco.
Oct. 2-5 — Am. Neurological Assoc., New Orleans.
Oct. 5-8 — Am. Thyroid Assoc., New Orleans.
Oct. 7-8 — AMA Congress on Occupational Health,
Beachwood, OH.
Oct. 16-21 — Am. College of Surgeons, Atlanta.
Oct. 22-27 — Am. Academy of Pediatrics, San Fran-
cisco.
Oct. 23-26 — Am. College of Gastroenterology, Los
Angeles.
Oct. 23-27 — Am. College of Chest Physicians,
Chicago.
Oct. 24-27 — Am. College of Emergency Physicians,
Atlanta.
Oct. 26-30 — Am. Academy of Child Psychiatry, San
Francisco.
Nov. 6-9 — Scientific Assembly, Southern Medical
Assoc., Baltimore.
Nov. 7-9 — Am. Medical Women’s Assoc., Dearborn,
MI.
Nov. 18-22 — Gerontological Society of Am., San
Francisco.
Nov. 30-Dec. 1 — Am. College of Chemosurgery,
Chicago.
1984
Jan. 27-29 — 17th Mid-Winter Clinical Conference,
Charleston.
March 17 — Annual Meeting, W. Va. Affiliate,
American Diabetes Assoc., Wheeling.
158
The West Virginia Medical Journal
WHY BMW CHOSE
TO CHANGE THE
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So after six years the sedan Car and Driver nominated “the quintessential
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machine with a totally redesigned, fully independent suspension system, new
aerodynamics, new technology, and a new fuel injection system that^^
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The result is not only a new car, but an apparent logical impossi-
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ROUTE 60, WEST ST. ALBANS 722-4900
WVU Medical Center
-News-
Compiled from material furnished by the Medical Center
News Service, Morgantown , W. Va.
H ow Should You Diagnose, Treat
Borderline Hypertension?
There is some disagreement among doctors
concerning just what constitutes mild elevation
of blood pressure and how it should be treated.
“The controversy comes from the fact that we
don't really know where the fine dividing line
between normal blood pressure and hypertension
is,” said Dr. Stanley R. Shane, Professor and
Interim Chairman of Medicine.
The most important issue, lie continued, in
determining whether to treat borderline hyper-
tension is the presence or absence of other risk
factors — primarily family history of high blood
pressure, obesity, diabetes and abnormal blood
cholesterol or triglyceride values. Smoking and
a sedentary lifestyle along with high stress or
driving-type personality are believed to contrib-
ute to elevated pressures, particularly when com-
bined with the other risks.
Related to Body Weight
“Blood pressure is distinctly related to body
weight,” he stated. “We don't understand why.
There’s a fair amount of data that’s been looked
at with no clear-cut relationship. But often if
people reduce their weight, sometimes by just 10
pounds, their blood pressure will be lowered and
they can avoid medication.
Doctor Shane said be believed physicians
might justify not treating patients with border-
line pressure elevations and no other risk factors
with the realization that the actual average pres-
sure is probably lower than that.
“But on the other hand, that says a great deal
about the role of stress," he explained. “If a per-
son’s blood pressure rises because of a visit to the
doctor, is there a similar response to other stress-
ful situations?
“I've seen patients who are on a sackfull of
medicine — and their blood pressure is still not
well controlled- -who will decide to leave a
job they’ve found stressful for years. It's striking
xvi
to see their blood pressure return to normal. In
fact, often I have to discontinue some of the
medication.”
Early treatment, in most cases of borderline or
moderate hypertension should include stress
management, weight control and salt restriction.
Doctor Shane said. Also needed is development
of a good health maintenance program with
exercise.
These instructions are seemingly easier for the
physician to give than for the patient to follow,
in many cases.
Patient Compliance Difficult
“Part of patient compliance is a matter of
education. Doctor Shane said. “It's very diffi-
cult dealing with hypertension because hyper-
tension doesn’t cause pain or discomfort. If
hypertension were associated with pain, you'd
have no problem with compliance.
“You always have to speak to patients in terms
of future benefits — not today, not even tomor-
row, but sometimes as much as 10-20 years down
the road. Hypertension has its effects over the
long term. It’s not an immediate thing, so it’s
always difficult to talk to a patient about follow-
ing a program or taking medication to prevent
something that's going to happen 20 years from
now.”
Dr. Ludwig Gutmann Elected
Neurologists’ Officer
Dr. Ludwig Gutmann, Chairman of the De-
partment of Neurology, has been named Presi-
dent Elect of the Association of University Pro-
fessors of Neurology.
Doctor Gutmann has been Secretary-Treasurer
for the past four years. Association membership
includes all chairmen of departments of neu-
rology in the United States.
Doctor Gutmann, who has headed the WVU
Neurology Department since 1970, is a gradu-
ate of Princeton University, and received his
medical degree from Columbia University. He
was named to the National Board of Medical
Examiners last, fall.
The West Virginia Medical Journal
HIGHLAND HOSPITAL
56TH & NOYES AVE., S.E.
CHARLESTON, W. VA. 25304
925-4756
MEDICAL STAFF
ADULT PSYCHIATRY
Miroslav Kovacevich, M. D.
925-0693
Charles C. Weise, M. D.
925-2159
Thomas S. Knapp, M. D.
925-3554
Pablo M. Pauig, M. D.
343-8843
Ralph S. Smith, M. D.
925-0349
Lee L. Neilan, M. D.
925-0349
Edmund C. Settle, Jr., M. D.
925-6914
Gina Puzzuoli, M. D.
925-6914
John P. MacCallum, M. D.
925-6966
CHILD PSYCHIATRY
Henrietta L. Marquis, M. D.
925-3160
Pablo M. Pauig, M. D.
343-8843
Ralph S Smith, M. D.
925-0349
John P. MacCallum, M. D.
925-6966
Psychiatric treatment for the emotionally
disturbed children ages 5 to 13 now avail-
able in new children's pavilion. Separation
maintained from adult psychiatric care
unit. Each program offers:
• Crisis Intervention
• Group Therapy
• Psychotherapy
• Activities & Recreational Therapies
• Skilled Attention to Family, Marital, and
Individual Emotional Problems
• Special Care for the Acutely Disturbed
Patient
• Staffed by Qualified Psychiatrists and
Medical Consultants
• Schooling Provided on Children’s Pa-
vilion
• Serving the Community for Over 25
Years
GOLDEN MEDICAL GROUP
1200 Harrison Avenue
ELKINS, WEST VIRGINIA
ANESTHESIOLOGY:
Y. H. Chung, M. D.
COMMUNITY MEDICINE:
R. C. Gow, M. D.
(Thomas Clinic)
S. O. Chung, M. D.
M. C. Rosenberg, D. O
(Helvetia Clinic)
EMERGENCY MEDICINE:
R. H. Plummer, D. O.
A. M. Fuller, M. D.
F. A. Khan, M. D.
D. J. Lloyd, M. D.
FAMILY PRACTICE:
L. H. Valliant, M. D.
C. S. High, M. D.
INTERNAL MEDICINE:
Gastroenterology:
S. S. Masilamani, M. D.
Allergy & Rheumatology:
J. B. Magee, M. D.
Cardiology:
H. L. Jellinek, M. D.
R. B. Garrett, M. D.
Metabolic & Endocrine Diseases:
F. Becerra, M. D.
Pulmonary Diseases:
J. C. Arnett, Jr., M. D.
OBSTETRICS & GYNECOLOGY:
H. H. Cook, Jr., M. D.
J. F. de Courten, M. D.
J. J. Rizzo, M. D.
M. W. Strider, M. D.
OPHTHALMOLOGY:
J. N. Black, M. D.
ORTHOPAEDIC SURGERY:
J. G. Gomez, M. D.
OTOLARYNGOLOGY
(Facial Plastic and
Reconstructive Surgery):
J. A. Wolfe, M. D.
PATHOLOGY:
M. M. Stump, M. D.
PEDIATRICS:
Y. J. Kwon, M. D.
R. J. Haas, M. D.
PSYCHIATRY:
R. W. O'Donnell, M. D.
RADIOLOGY:
F. H. Abdalla, M. D.
H. Y. Mang, M. D.
C. P. O’Sullivan, M. D.
SURGERY:
General, Thoracic & Vascular:
J. A. Noronha, M. D.
W. B. Blum, M. D.
B. R. Blackburn, M. D.
R. A. Rose, M. D.
UROLOGY:
D. T. Chua, M. D.
July, 1983, Vol. 79, No. 7
xvn
Third-Party News, Views
and Program Concerns
Workers’ Compensation Fee
Schedule Planned
Workers’ Compensation Commissioner Gret-
chen 0. Lewis lias advised medical providers
that the Workers’ Compensation Fund is in the
process of developing a medical fee schedule and
updating its computerized claim system.
A provision of state statute stipulates that
“the commissioner shall establish, and alter from
time to time as he ( or she) may determine to be
appropriate, a schedule of the maximum reason-
able amounts to be paid to physicians, surgeons,
hospitals or other persons, firms or corporations
for the rendering of treatment to injured em-
ployees . . .
In her letter to providers, Ms. Lewis had these
other comments:
“To insure prompt and correct payment to the
providers and to permit our monitoring of the
services rendered, we find it necessary to re-
quire the proper CPT Code, in addition to a
narrative description of the treatment rendered,
when submitting fee bills to this office.
“This has been a requirement for some time,
hut has not been strictly enforced. However,
effective July 1, 1983, we will no longer accept
any fee hills without the proper CPT Codes.
“Current Procedural Terminology (Fourth Edi-
tion I code hooks may he purchased from ‘Order
Department OP-041, American Medical Asso-
ciation. P.0. Box 10946, Chicago. IL 60610 .”
These CPT Code Books are presently available at
the cost of $23.45 each, including postage and
handling.”
‘Squeal Rule’ Still Wanted
By Administration
Early this year, judges in both Washington
and New \ ork blocked the controversial “squeal
rule” which requires federally-funded family
planning clinics to notify parents when their
teenagers receive prescription contraceptives.
But, in May the Reagan Administration went
xviii
back to the Washington, D.C., Appeals Court to
urge reinstatement of the rule.
Government appeal of the second suit, filed by
New York State’s Attorney General, was sent to
be heard in New York in June, the American
Medical Association reported.
Action Postponed in West Virginia
In West Virginia, an Appeals Court postponed
action on a third suit after the Washington and
New York rulings.
In Utah, a federal judge has blocked a state
“squeal rule” until a full hearing is held.
Attorneys for the Administration say that a
1981 amendment passed by Congress was de-
signed to make parents more involved in their
children’s sexual decision-making. Simply en-
couraging teenagers to talk to their parents has
not helped reduce the number of teenage preg-
nancies, they say.
“It is absolutely clear that the Secretary of
Health and Human Services had the authority to
issue the regulations challenged in this case,”
argued Justice Department lawyer Carolyn B.
Kuhl before the Washington, D.C., judge. “The
family cannot participate in an activity that it
does not know is taking place ...”
But family planning groups charge that the
“squeal rule” invades a teenager’s right to pri-
vacy and violates patient-physician confiden-
tiality. Furthermore, there is little basis for the
government’s contention that notification would
protect the health of teenagers; prescription con-
traceptives pose few problems to women under
age 18, they say.
AMA Against ‘Squeal Rule’
The AMA and the American College of Ob-
stetricians and Gynecologists, siding with the
family planning groups, contend that a notifica-
tion rule will scare teenagers away from family
planning clinics and lead to an upsurge in ado-
lescent pregnancies. “Teens are five times more
likely to die from pregnancy and childbirth than
from the use of oral contraceptives,” Dr. Luella
Klein, ACOG’s Vice President, said at a press
conference earlier this year.
The West Virginia Medical Journal
Obituaries
V. R. ANUMOLU, M. D.
Dr. V. R. Anumolu, Fairmont internist, died
on May 31 when fire burned the Myrtle Beach.
Soutli Carolina, beachhouse in which he was
sleeping. He was 37.
Doctor Anumolu’s wife, Sarojini Anumolu.
also died in the fire.
Doctor Anumolu was a former member of the
West Virginia State Medical Association.
A native of India, he had practiced in Fair-
mont for approximately seven years.
* * *
SAM MILCHIN. M. D.
Dr. Sam Milchin, retired Bluefield general
practitioner, died on May 31 at his home. He
was 72.
A native of Richmond. Virginia. Doctor Mil-
chin was graduated from the University of Rich-
mond, and received his M. D. degree in 1935
from the Medical College of V irginia.
He began practice in Bishop, Virginia, and
Jenkinjones. West Virginia, moving to Bluefield
in 1953. He then opened his office in Bluefield.
Virginia. Residents of both Bluefields and the
surrounding areas were among his patients.
Upon his recent retirement, the community
honored him with a dinner tribute.
Doctor Milchin was a World War II Navy
veteran.
He was a member of the Mercer County
Medical Society, West Virginia State Medical
Association and American Medical Association.
Surviving are the widow and two daughters,
Mrs. Tom Garrett and Susan Milchin. both of
Richmond.
OPENING FOR
CARDIOLOGIST
INVASIVE CARDIOLOGIST, hospital
rounds duties and some diagnostic testing.
Mid-Atlantic states area. Abilities to do
streptokinase and/or angioplasty desir-
able. Salary and bonus. Respond with C-V
to Box PAL, c/o The West Virginia Medical
Journal, P. O. Box 1031, Charleston, WV
25324.
County Societies
CENTRAL WEST VIRGINIA
Dr. Frederick C. Whittier of Morgantown was
the guest speaker for the spring meeting of the
Central West Virginia Medical Society on May 5
in Jacksons Mill at the Deerfield Country Club.
Doctor Whittier. Chairman of the Department
of Nephrology, West Virginia University Medical
Center, discussed hypertension and nephrology.
The Society approved two scholarships of $225
each to Camp Kno-Koma, and a sustaining do-
nation of $50 to the American Medical Associa-
tion’s Medical Student Section. — Greenbrier Al-
mond, M. D., Secretary-Treasurer.
* # *
WESTERN
The Western Medical Society met on May 10
in Ripley at the McCoys Motor Lodge.
The host for the evening was The John Han-
cock Insurance Company, whose representative,
Tom Leadbetter, was the guest speaker. His
topic was “Personal Financial Planning.”
The Society will adjourn for the summer, with
the next meeting scheduled on September 13 at
Roane General Hospital in Spencer. — -Ali H.
Morad. M. D., Secretary-Treasurer.
* # *
PARKERSBURG ACADEMY
The Parkersburg Academy of Medicine met on
March 9 at the Parkersburg Country Club.
The guest speaker was Robert McHenry, Trust
Officer of Parkersburg National Bank, whose
topic was “Estate Planning, Wills and Trust.”
The Academy met again on April 13 at the
Parkersburg Country Club. Robert Shade, M. D.,
Associate Professor of Medicine, Division of
Gastroenterology, University of Pittsburgh, was
the guest speaker. His subject was “Peptic
Ulcer Disease-GI Bleeding.”
The Academy approved a donation of $225
for Camp Kno-Koma.
The Academy met again on May 11 at the
Parkersburg Country Club. The guest speaker
was Don Sensabaugh, an attorney with the
Charleston firm of Kay, Casto and Chaney, whose
topic was “Medical Malpractice.”
( continued on page xxiii )
July, 1983, Vol. 79, No. 7
xix
Professional
Liability Insurance
Designed for
West Virginia
Physicians
“The Association recommends
its endorsed program to you for...
your most considered review and
attention.”
Reprinted from The West Virginia Medical Journal, September 1981
Your Association’s Professional Liability Insurance Program Includes:
• A market guarantee with Continental Casualty Company,
CNA, the fourth-largest underwriter of professional liability
insurance in the United States.
• A consent to settle provision for doctors covered under the plan.
• An in-state managing general agent, McDonough Caperton Shepherd
Group, with offices located in five key West Virginia cities
to provide risk management and technical expertise in professional
liability matters.
• A payment plan with no finance charges.
• A profit-sharing mechanism.
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The West Virginia Medical Journal
Vol. 79, No. 8
August, 1983
Effect of Ethrane Supplementation On Intrapulmonary
Shunting In Dogs
Anesthetized With Nitrous Oxide And Morphine
DAVID F. GRAF, M. D.
Associate Professor of Anesthesiology, West Virginia
University School of Medicine, Morgantown
LAWRENCE M. LAVINE, M. D.
Assistant Professor of Anesthesiology,
University of Chicago School of Medicine,
Chicago, Illinois
This study involving eight mongrel dogs was
undertaken to determine whether pulmonary
oxygenation is adversely affected by the supple-
mentation of enflurane to nitrous narcotic
anesthesia under normal states of cardiovascular
and respiratory function.
The results indicate that under normal states
of respiratory and cardiovascular function , sup-
plementation of enflurane to morphine-N^O-O-z
anesthesia in response to painful stimuli has no
adverse effect on pulmonary oxygenation.
Intrapulmonary shunting and arterial pO 2 were
unchanged from baseline values ( p>.05) except
at 45 minutes when intrapulmonary shunting was
actually decreased (p<.05).
eneral anesthesia, by producing decreased
FRC. increased small airway closure, micro-
atelectasis and altered ventilation/perfusion
ratios, causes regional alveolar hypoxia. This
regional alveolar hypoxia is partially compen-
sated by pulmonary hypoxic vasoconstriction,
which redistributes blood flow from hypoxic
alveoli to normoxic alveoli. 1 Since the first
description of this phenomenon, 2 numerous
studies have been performed in man and animals
determining that hypoxic pulmonary vasocon-
striction is relatively spared by narcotics and
nitrous oxide, but may he inhibited by halothane
or enflurane. 3 ' 4,5,6,/
To insure adequate pulmonary oxygenation,
some anesthesiologists routinely increase the
FiOi> of inspired gases when they supplement
nitrous-narcotic anesthesia with enflurane. The
purpose of this study was to determine whether
this practice is really necessary.
Eight mongrel dogs, weighing 18-22 kg., were
given an infusion of four ml/kg of D5RL, and
then were infused with four ml/kg/hour of
D5RL during the experiment. The dogs were
anesthetized with four mg/kg sodium pentothal,
given one mg/kg succinylcholine and intubated
with a cuffed endotracheal tube. Anesthesia was
maintained with 66 per cent NiO, 33 per cent
0i>, and one half mg/kg morphine sulfate. The
dogs were given 0.4 mg/kg curare and mechani-
cally ventilated maintaining a pCOi- of 35-40
torr. An arterial line and a Swan Ganz catheter
were introduced. Blood pressure and heart rate
were continuously monitored.
Baseline Data
One hour after induction of anesthesia, the
following baseline data were obtained: systemic
arterial pressure, arterial blood gas, mixed
venous PO;;, cardiac output (via thermodilution
method), and heart rate. Blood removed for
sampling was immediately replaced with an
equal volume of D5RL. After baseline data
were obtained, the tails of the dogs were
clamped. In response to this stimulus, enflurane
was administered to maintain the mean arterial
pressure at 80 per cent of its preclamping value.
August, 1983, Vol. 79, No. 8
159
Additional sets of data were collected five
minutes, 15 minutes, and 45 minutes after tail-
clamping.
The intrapulmonary shunt was calculated from
the following equation:
shunt — Cc’ - Ca
Cc’ - Cv
Cc’ is the oxygen content in the pulmonary
end-capillary blood.
Ca is the oxygen content of arterial blood.
Cv is the oxygen content of mixed venous
blood.
Cc’ is calculated from tbe “ideal” alveolar
Po:> (itself calculated from tbe Alveolar Air
Equation ), the hemoglobin content of the blood,
and tbe relationship between P0_> and saturation
of hemoglobin (tbe oxygen dissociation curve).
Data Compared
The data obtained for each time interval were
compared with the corresponding pre-clamping
values by use of the paired T-test. As expected,
the mean values of the arterial pH, pCCE,
cardiac output, and heart rate were unchanged
from their control values for all time periods
(p>0.05). Mean arterial pressure was approxi-
mately 80 per cent of its control value for all
time periods.
Of significance were the results obtained for
the arterial pCC and tbe intrapulmonary shunt.
The mean arterial pCE was unchanged for all
time periods (p>0.05). The intrapulmonary
shunt was unchanged from its control value in
40 per cent of the dogs, and was decreased by
50 per cent of its baseline value in the other
60 per cent of the dogs. Overall, the average
intrapulmonary shunt was slightly decreased at
the five- and 15-minute time intervals, and was
significantly reduced at the 45-minute time inter-
val (p<0.05).
In conclusion, it appears that under normal
states of respiratory and cardiovascular function,
supplementation of enflurane to morphine-
N-O-CE anesthesia in response to painful stimuli
has no adverse effect on pulmonary oxygenation.
References
1. Fishman AP: Respiratory gases in the regulation of
pulmonary circulation. Physiol 1961; 41:214-280.
2. Beyhe J : Influence de panoxemie sur la grande
circulation et sur la circulation pulmonaire. Compt Rend
Soc Biol 1942; 136:399-400.
3. Sykes MK et al .: Preservation of the pulmonary
vasoconstrictor response to alveolar hypoxia during the
administration of halothane to dogs. Br J Anaesth 1978;
50:1185-1196.
4. Bjertnaes LJ et al.: Hypoxic pulmonary vasocon-
striction: Inhibition due to anesthesia. Acta Physiol
Scand 1976; 96:283-285.
5. Mathers J et al.: General anesthetics and regional
hypoxic pulmonary vasoconstriction. Anesthesiology 1977 ;
46:111-114.
6. Price HL et al.: Pulmonary hemodynamics during
general anesthesia in man. Anesthesiology 1969; 30:629-
636.
7. Gibbs JM, Johnson H: Lack of effect of morphine
and buprenorphine on hypoxic pulmonary vasoconstriction
in the isolated, perfused cat lung and the perfused lobe
of the dog lung. Br J Anaesth 1978; 50:1197-1199.
160
The West Virginia Medical Journal
Dopamine-Modulating Drugs, Amenorrhea-Galactorrhea
And Neuropsychiatric Illnesses
PAUL E. FRYE, M. D.
Fairmont, West Virginia; Clinical Assistant Professor
of Behavioral Medicine and Psychiatry, West Virginia
University School of Medicine, Morgantown
The properties and clinical uses of drugs that
alter dopamine function in the brain are
discussed in relationship to hypotheses in
psychoneuroendocrinology. Established and po-
tential treatments in the three related medical
disciplines are discussed. The role of dopamine
and its receptors in psychiatric illnesses, move-
ment disorders, and amenorrhea-galactorrhea is
emphasized. Treatment in one area may result
in altered function in other systems in which
dopamine has a role.
-pVRUGS that facilitate or inhibit dopaminergic
transmission in the central nervous system
( CNS ) are used in many areas of medicine.
Modifying the activity of dopaminergic systems
in the CNS has psychiatric, neurologic and en-
docrinologic effects. The purpose of this paper
is to discuss the drugs, the hypotheses, and the
clinical aspects of dopamine modulation.
Phenothiazines, such as chlorpromazine
(Thorazine), were introduced in this country
as antipsychotics three decades ago; sub-
sequently, physicians have used effectively a
number of neuroleptic compounds in the treat-
ment of schizophrenia and affective disorders.
Amphetamines and other CNS stimulants have
been used as antidepressants and anorexic
agents. They are presently accepted treatment
for narcolepsy and attention deficit disorders.
The usefulness of levodopa (Sinemet) in
Parkinsonism was followed by the discovery of
additional anti-Parkinson agents among the ergot
alkaloids. These compounds have a structural
similarity to dopamine. 1 Chemical modification
has produced related compounds with less
vasoconstrictor and uterine effects, than are com-
mon in the naturally-occurring ergot alkaloids.
These derivatives include bromocriptine, which
retains the property of dopamine facilitation and
the ability to inhibit prolactin secretion. Ameri-
can clinicians recently have begun using bromo-
criptine mesylate (Parlodel) to treat hyper-
prolactinemia. 2 In Europe, bromocriptine has
found application in a variety of endocrine dis-
orders, including acromegaly.' 1
Pharmacologic properties of the opiate
alkaloid apomorphine, including its potency for
inducing emesis, have precluded its use in
Parkinsonism, but it has been an important
compound in research in the pharmacology of
dopaminergic systems. Apomorphine is pre-
sumed to be a “direct’’ stimulator of dopamine
receptors, because its effects are not altered by
drugs that inhibit the production or storage of
intrinsic dopamine. 4 (Thus it is appropriately
called a dopamine agonist, while amphetamines
and other compounds that facilitate transmission
via intrinsic dopamine are not.)
Hypotheses in Psychiatry, Neurology,
and Endocrinology
Dopamine is released into synapses in the
nigrostriatal. mesolimbic, and tuberoinfundibu-
lar (or tuberohypophyseal ) systems. It has
various effects as a result of interaction with
post-synaptic receptors, and also acts in direct
inhibitory feedback by way of autoreceptors on
the cell of origin. Dopamine-modulating drugs
vary in their direct or indirect effects on pre-
synaptic and postsynaptic receptor activity.
Whether the presynaptic (inhibitory) effect will
predominate is believed to depend on concentra-
tion for some drugs. For example, low doses of
apomorphine result in predominantly presynaptic
activity and. thus, an inhibitory influence (in
contrast to its property of dopamine agonism at
higher doses ) . 4,-> ' 6 Biochemical findings that
implied increased turnover of dopamine during
neuroleptic treatment led Carlsson and Lindqvist
to speculate, in 1963, that the mode of action
of antipsychotic drugs is blockade of dopamine
receptors.
Additional data subsequently have supported
and modified a “dopamine hypothesis’’ for the
etiology of schizophrenia. 8 The hypothesis is
that schizophrenia is a result of excessive activity
of dopaminergic neural systems. Previously well
patients occasionally develop neuropsychiatric
syndromes as a result of toxic effects of ingested
substances. Drugs known to facilitate dopamine
have been associated with psychiatric syndromes
resembling schizophrenia or affective disorder.
Paranoid ideation, delusions, hallucinations,
inappropriate behavior, disorders of thinking,
and affective disturbances have been documented
following use of levodopa, amphetamine, co-
August, 1983, Vol. 79, No. 8
161
caine, methylphenidate (Ritalin), bromocriptine,
and lergotrile. 9,10 The occurrence of such
syndromes in persons presumably without
psychiatric illness gives impetus to the assump-
tion that ingestion of these drugs would exacer-
bate the illness of persons with schizophrenia,
which by hypothesis means vulnerable dopami-
nergic neural systems. Stimulants and ergot
alkaloids do increase psychotic symptoms in
some (but not all) schizophrenics. 8,11 This is
compatible with the dopamine hypothesis of
schizophrenia.
Altered dopaminergic function also has been
postulated in attempts to explain the etiology of
affective disorders. Randrup and Braestrup
interpret data and cite reviews supporting a
dopamine hypothesis of depression. 12 Various
authors have reported evidence of a dopami-
nergic mechanism in mania. 12,13
Parkinsonism, Receptor Changes
The association of degeneration of dopami-
nergic systems in the substantia nigra with
Parkinsonism led to a search for a dopamine
precursor. 8 The success of levodopa in treat-
ment of this crippling illness and the mimicking
of Parkinson’s disease as an adverse effect of
neuroleptics that are potent dopamine antag-
onists support the assumption of decreased
dopaminergic function in the etiology of Parkin-
sonism.
Prolonged alterations of neurotransmitter
function result in receptor changes. Tardive
dyskinesia involves rhythmic, involuntary move-
ments of the orofacial, limb or trunk muscles,
and it is associated with neuroleptic treatment. 14
In order to explain the occurrence of tardive
dyskinesia during or following neuroleptic drug
use, an increased sensitivity, similar to the type
seen following denervation, has been postulated
to occur in central dopamine receptors. 1 ’ In
th is model, prolonged blockade of receptors
leads to supersensitivity; withdrawal of the
blocking agent is followed hy a rebound effect
of greater transmission than normal. Bunney
et al. reviewed evidence suggesting that lithium
can block or modify the development of super-
sensitivity in CNS dopamine receptors. 16
A number of physiologic and non-physiologic
processes can elevate prolactin levels and produce
amenorrhea and galactorrhea. Dopamine-modu-
lating drugs have pronounced effects on pro-
lactin: antagonism of dopamine results in hyper-
prolactinemia, while dopamine agonists lower
prolactin levels. 2 Primary control of prolactin
secretion is hy tuberoinfundibular dopaminergic
neurons that terminate at the hypophyseal portal
system; regulation occurs by release of a pro-
lactin-inhibitory factor that is probably dopa-
mine itself. 3
Dopamine appears to provoke human growth
hormone (HGH) release under normal condi-
tions. Levodopa, apomorphine, and bromocrip-
tine increase HGH secretion in normal persons;
however, in patients with acromegaly, the same
medications paradoxically decrease excessive
growth hormone levels. Several authors have
speculated on the role of dopamine in regulating
HGH, but as yet no explanation for this
phenomenon is fully satisfactory. 3
Clinical Aspects of Dopamine Modulation
The use of neuroleptics, stimulants, and anti-
Parkinson agents to modify transmission in
dopaminergic systems is well-established. Their
adverse effects include toxic psychoses, drug-
induced movement disorders, and amenorrhea-
galactorrhea. Most physicians are skilled in early
recognition and treatment of extrapyramidal
reactions to neuroleptics. On the other hand,
amenorrhea, galactorrhea, and adverse effects on
sexuality generally have gone without emphasis.
Screening for these troublesome and unintended
results may reveal problems in as many as one
woman in two, or one in 10 men. 1 '
Amenorrhea and galactorrhea have been as-
sociated with neuroleptics since shortly after the
introduction of the phenothiazines in the
1950s. 18 For all neuroleptics of each chemical
family, nearly all patients have elevation of
plasma prolactin within three days. 17,19 Apostol-
akis et al. reported a study of 260 patient^: 50
per cent of females and 10 per cent of males,
taking psychotropic drugs known to cause
hyperprolactinemia, developed some degree of
inappropriate lactation. 20 A higher than normal
frequency of amenorrhea has been reported
among patients with untreated psychiatric dis-
orders. 18 As a result, it is difficult to conclude
what proportion of amenorrhea during neuro-
leptic treatment to attribute to drug effect.
Nonetheless, elevated prolactin is clearly a major
cause of amenorrhea, whether or not it is ac-
companied by galactorrhea. 2
Bromocriptine mesylate has been approved by
the U. S. Food and Drug Administration for
treatment of amenorrhea-galactorrhea of various
etiologies, excluding demonstrable pituitary
tumor; more recently, it was approved for post-
partum inhibition of lactation. Conversely,
experience with dopamine agonists for treatment
of endocrine disorders is limited. Because we
are unable to forecast which patients are at risk
for exacerbation of psychiatric symptoms, it is
162
The West Virginia Medical Journal
difficult to justify the use of bromocriptine or
other dopamine agonists as the initial treatment
for neuroleptic-induced amenorrhea-galactorrhea.
( Alternatives with less risk are discussed below. )
When bromocriptine must be prescribed for
patients with a history of schizophrenia or affec-
tive disorder, low initial dosage and small in-
crements thereafter are preferable in order to
minimize psychiatric complications. Frequent
assessment of mental status is critical. If
neuropsychiatric disturbance does occur, it
appears to be reversible, at least during the early
stages of bromocriptine treatment. 21 The large
number of physiologic and pathologic processes
that can cause hyperprolactinemia mandates that
all patients with amenorrhea-galactorrhea have a
thorough evaluation prior to starting bromo-
criptine. This includes endocrine studies and
tomographic roentgenograms of the sella
turcica. 22
When a patient develops amenorrhea-galacto-
rrhea during neuroleptic treatment and has no
indication of another etiology, the physician has
several options for an initial approach. Eleva-
tion of prolactin by neuroleptics is dose-related
and quickly reversible. 19 Thus, one choice is
to lower the dose of neuroleptic. (Using the
lowest effective dose also has been advocated to
produce the least interference in cognitive func-
tion and to reduce the risk of neuroleptic-in-
duced (tardive) dyskinesia. 23 ) Another option
is to change medications since each neuroleptic
raises prolactin to a different degree. 19
Psychiatric Applications
Despite the importance of caution in clinical
use of bromocriptine and other dopamine
facilitators for patients with psychiatric illness,
experimental uses of drugs that increase
dopaminergic function suggest potential psychi-
atric applications of this property. Bromo-
criptine, apomorphine, and piribedil (all dopa-
mine agonists ) have been reported useful in
mania. 13 Recent cases have appeared in the
literature reporting the use of methylphenidate
in the treatment of depression among elderly
patients for whom standard treatments were
contraindicated. 24
Steiner and Carroll reviewed the literature
supporting the utility of bromocriptine in pre-
menstrual dysphoria syndrome. 25 When Tam-
minga et al. gave apomorphine in low doses to
test the presynaptic dopamine inhibition hypo-
thesis, nine of eighteen schizophrenic patients
had 20- to 50-per cent reduction of symptoms
(compared to placebo): some stopped halluci-
nating; some lost their delusions. 6 Friedhoff
reported success using levodopa to treat tardive
dyskinesia; his hypothesis is that supersensitive
dopamine receptors are “retuned” to lower
sensitivity by brief overstimulation and resultant
compensation. 15
Conclusion
Dopamine blockade has brought major ad-
vances in psychiatric treatment. Other modifi-
cations of dopaminergic transmission in the CNS
are established treatment in neurology, psychi-
atry, and endocrinology, or offer potential bene-
fits on these frontiers. These advances have
promoted new understanding of brain function;
yet. the adverse effects of dopamine modulation
remain.
Psychiatrists will continue to utilize dopamine-
blocking neuroleptics when indicated, until bet-
ter treatment is found. It is important that pri-
mary care physicians be aware that neuroleptic
drugs are a common cause of amenorrhea and
galactorrhea, and that treating with dopamine
agonists carries risks that are not eliminated
simply because the patient is in remission or is
taking neuroleptic medication.
When physicians evaluate patients with acute
mental status changes, drug-induced facilitation
of dopaminergic transmission must be included
in the differential diagnosis. For example, a
person with bromocriptine-induced organic de-
lusional syndrome (toxic organic brain syn-
drome ( must be differentiated from “schizoph-
renic.” Early intervention may prevent the
detrimental interpersonal, intrapsychic, bio-
chemical, and social-vocational changes that can
result from the internal events and external
manifestations of psychosis or from stigmata
that follow diagnostic labeling. Alertness to this
distinction may avert unnecessary suffering.
Editor s Note : Here are the generic drugs and
trade names (in parentheses) to which reference
is made in this manuscript : bromocriptine mesy-
late (Parlodel) ; chlorpromazine (Thorazine);
levodopa (Sinemet); and methylphenidate
( Ritalin ).
References
1. Parkes D: Bromocriptine. N Engl J Med 1979;
301:873-878.
2. Frantz AG: Prolactin. N Engl J Med 1978; 298:
201-207.
3. Spark RF, Dicks tein G: Bromocriptine and endo-
crine disorders. Ann Intern Med 1979; 90:949-956.
4. Cooper JR, Bloom FE, Roth RH: Effect of drugs
on the activity of dopaminergic neurons, in The Bio-
chemical Basis of Neuropharmacology, New York, Oxford,
1978, pp 183-186.
August, 1983, Vol. 79, No. 8
163
5. Muller EE, Nistico G, Scapagnini U: Metabolism
of dopamine, in Neurotransmitters and Anterior Pituitary
Function, New York, Academic Press, 1977, pp 57-64.
6. Tamminga CA, Schaffer Mil. Smith RC, Davis JM:
Schizophrenic sysmptoms improve with apomorphine.
Science 1978; 200:567-568.
7. Snyder SH, Banerjee SP, Yamamura HI, Greensburg
D: Drugs, neurotransmitters, and schizophrenia. Science
1974; 184; 1243-1253.
8. Snyder SH: The dopamine hypothesis of schizo-
phrenia: Focus on the dopamine receptor. Am J Psy-
chiatry 1976; 133:197-202.
9. Klawans HL, Margolin DI: Amphetamine-induced
dopaminergic hypersensitivity in guinea pigs: Implica-
tions in psychosis and human movement disorders. Arch
Gen Psychiatry 1975; 32:725-732.
10. Serby M, Angrist B, Lieberman A: Mental dis-
turbances dining bromocriptine and lergotrile treatment
of Parkinson’s disease. Am J Psychiatry 1978; 135:1227-
1229.
11. Tamminga CA, Schaffer MH : Treatment of schizo-
phrenia with ergot derivatives. Psychopharmacol 1979;
66:239-242.
12. Randrup A, Braestrup C: Uptake inhibition of
biogenic amines by newer antidepressant drugs: Rel-
evance to the dopamine hypothesis of depression. Psy-
chopharmacol 1977; 53:309-314.
13. Gerner RH, Post RM, Bunney WE: (letter) Dr.
Gerner and associates reply. Am J Psychiatry 1977; 134:
703.
14. Ananth J : Tardive dyskinesia: Myths and realities.
Psychosomatics 1980; 21:389-396.
15. Friedhoff AJ : Receptor sensitivity modification
(RSM)— a new paradigm for the potential treatment of
some hormonal and transmitter disturbances. Comp
Psychiatry 1977; 18:309-317.
16. Bunney WE, Pert A, Rosenblatt J, Pert CB, Gal-
laper D: Mode of action of lithium: Some biological
considerations. Arch Gen Psychiatry 1979; 36:898-901.
17. Dickey RP, Stone SC: Drugs that affect the breast
and lactation. Clin Obstet Gynecol 1975; 18:95-111.
18. Beumont PJV, Gelder MG, Friesen HG, Harris
GW, Mackinnon PCB, Mandelbrote BM, Wiles DH: The
effects of phenothiazines on endocrine function: I. Pa-
tients with inappropriate lactation and amenorrhea. Br J
Psychiatry 1974; 124:413-49.
19. Meltzer HY, Fang VS: The effect of neuroleptics
on serum prolactin in schizophrenic patients. Arch Gen
Psychiatry 1976; 33:279-286.
20. Apostolakis M, Kapetanakis S, Lazos G, Madena-
Pyragaki A: Plasma prolactin activity in patients with
galactorrhea after treatment with psychotropic drugs, in
Wolstenholme GEW, Knight J (eds): Lactogenic Hor-
mones. CIBA Found Symp, 1972, pp 349-351.
21. Frye PE, Pariser SF, Kim MH, O’Shaughnessy
RW: Bromocriptine associated with symptom exacerba-
tion during neuroleptic treatment of schizoaffective
schizopluenia. J Clin Psychiatry 1982; 43:252-253.
22. Boyd AE, Reichlin S, Turksoy RN: Galactorrhea-
amenorrhea syndrome: Diagnosis and therapy. Ann
Intern Med 1977; 87:165-175.
23. Hansell N: Approaching long-term neuroleptic
treatment of schizopluenia. JAMA 1979; 242:1293-1294.
24. Katon W, Raskind M: Treatment of depression
in the medically ill elderly with methylphenidate. Am J
Psychiatry 1980; 137:963-965.
25. Steiner M, Carroll BJ: The psychobiology of
premenstrual dysphoria: Review of theories and treat-
ments. Psychoneuroendocrinology 1977; 2:321-335.
Drug Prevents Hemorrhages In Injured Eye
R esearchers at theUniversity of Illinois Eye and Ear Infirmary, Chicago, have dem-
onstrated conclusively the safety and efficacy of a heretofore neglected treatment to
prevent recurring hemorrhage in an injured eye.
Their report in a recent issue of Archives of Ophthalmology shows that aminocaproic
acid administered in precisely calculated doses can reduce significantly the incidence of
secondary hemorrhage after blunt (nonperforating) trauma to the eye. The drug,
a synthetic amino acid, works by inhibiting dissolution of blood clots and consequent
reopening of ruptured ocular blood vessels, according to John J. McGetrick, M. D.
164
The West Virginia Medical Journal
116th ANNUAL MEETING
of the
West Virginia State Medical Association
ZJhe Green brier
AUGUST 25-27, 1983
PLAN NOW TD ATTEND
August, 1983, Vol. 79, No. 8
165
c/l menage front . . .
*jke president
HANGING TOGETHER
't'his is my last President’s Page. Dr. Carl Adkins
of Fayetteville will be installed as your President
at our Annual Meeting this month. While this has
been a fantastic year and has meant more, personally
and professionally, than I can express, I nonethe-
less confess to some small sense of relief that I will
be passing the gavel, especially to such a capable
person. During the past year, I discussed in these
pages issues that I felt were important to call to
your attention, such as improving communication,
involvement in the political process, cost contain-
ment, malpractice tort reform, efforts in caring for
the medically needy and the role of our organiza-
tion. While I am sure that there have been some
disagreements, I have been encouraged by the many
positive comments I have heard.
For my last message, I would like to address an
issue that is, in my view, a potential cause for con-
cern. I am concerned about the possibility of in-
creasing fragmentation of our profession into
smaller, limited-interest specialty groups. These
groups sometimes seem to have a very narrow
sphere of interest, and may not be as willing to take
a broader view of what is best for our patients and
for Medicine in general.
As a urologist, I am well aware of the importance
of the point of view of the specialist or subspecialist,
but the broader view may be required in these times.
Numerous outside pressures, such as governmental
economic constraints, third-party payor intervention
and the continuing malpractice crisis climate, are
threatening the foundations of our free-enterprise,
individual doctor-patient relationship, the basis for
the best medical care in the world. We must not for-
get that we are all doctors first, and specialists
second. This is not a reflection of a “circle the
wagons” mentality or in response to a perceived
threat by any group. It is a realistic appraisal of
problems potentially facing us. At a time when
severe economic constraints are being imposed on
health care by outside forces, we in Medicine —
united — must continue to stand firm for what we
believe in: quality — the best possible care for the
patient at the lowest possible cost. If we fragment
ourselves into smaller groups with conflicting in-
terests, then we may lose some of the influence we
can yield as a united group for the ultimate benefit
of our patients.
There is nothing wrong with differences of opinion
and candid, blunt discussion. This is very crucial
and needed, but if such discussion reaches the point
of dissension and discord, and sets group against
group or specialist against generalist, this serves
neither the best interests of our patients nor of
Medicine. There are legitimate differences of opinion
and outlook among groups of specialists, and even
groups of physicians within those specialties. The
place to bring these different viewpoints together
is through the framework of our State Medical
Association and of the AMA. There, honest differ-
ences of opinion can be aired, conflicting ideas re-
solved and a consensus reached. There is no doubt
that united we will have more influence for the
benefit of our patients than many smaller groups
can achieve.
These are trying times for the profession of
Medicine, and many changes are in sight. This is
no time for “business as usual” or limited self-
interest. We need innovative and imaginative ways
to deal with these changes and to preserve the
quality of care we have worked so hard to achieve.
In the words of Ben Franklin from our historical
past, “Gentlemen, we must all hang together, or
most assuredly, we shall all hang separately.”
I look forward to seeing you all at our Annual
Meeting to air your views and opinions; to make
your comments; to share your ideas, and finally, to
participate in reaching a consensus which will be-
come the policy for the West Virginia State Medical
Association. See you at the Greenbrier!
Harry Shannon, M. D., President
West Virginia State Medical Association
166
The West Virginia Medical Journal
The West Virginia Medical Journal
Editorials
The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or
in communications submitted to this Journal for publication. The author shall be held entirely responsible.
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State
Medical Association.
Physicians must communicate “among our-
selves, with our patients, with the media and
the Legislature," Harry Shannon, M. D., said
a year ago in assuming the Presidency of the
West Virginia State Medical Association.
He set some other guidelines for his year in
office, too. The public must be re-educated to
the fact that the vast majority
POSITIVE YEAR of physicians care first about
their patients. The state must
have a strong Board of Medicine because “if
we intend to show the public we are as concerned
about quality of care as indeed we are, then we
must demonstrate that concern."
Harry Shannon has carried those messages,
and many more, into every corner of the state
this past year — and has done so effectively. The
media consistently has picked up his thoughts
from the President’s Page in The Journal and
further broadcast them to the reading, listening
and viewing public.
Have all his visions become reality? No, and
that simply is an impossible thing to expect over
the short period of 12 months. But Carl R.
Adkins, M. D., is ready in the wings to pick
up on most of these major themes, and build
further on them, in his year ahead.
The past couple of years have brought a new
continuity in the office of President, with those
who recently have served involved in detailed
exchange of ideas and objectives with those
coming up the Association’s leadership ladder.
Never in the 116-year history of the organiza-
tion has this been more important.
Doctor Shannon clearly has learned many
things as he has trudged from his practice in
Parkersburg to Weirton in the north; McDowell,
Mingo and Mercer counties in the south: Jeffer-
son and Berkeley in the east, and Cabell and
Mason to the west.
He’s learned that there are physicians deeply
interested in the Association, and what it’s trying
to do. He’s encouraged more involvement of all
physicians, and has particularly urged that they
speak out about their concerns and their own
goals and values.
The more lines of communication “we can
open." he said last August, “the easier it will be
to resolve any differences and to achieve our goal
of the highest quality of care for our patients in
West Virginia.”
What critical tasks still lie ahead? There are
increasing numbers every year in this age of
rapid technological advance, a growing physician
population with eager young doctors with their
own views and values — and the constantly
broadening pressures upon Medicine and those
it serves from the general arena of government
and bureaucracy.
Within the Association, communication needs
much additional work. So do short and long-
Harry Shannon, M. D.
August, 1983, Vol. 79, No. 8
167
range planning; membership recruitment and
services; more effective and sophisticated risk
management programs, and a year-around
approach to legislative affairs.
The year has brought significant progress.
Further tightening and development of accredi-
tation for community hospital continuing medi-
cal education programs have underlined the fact
that West Virginia has one of the better such
efforts anywhere. Work in the area of profes-
sional liability insurance coverage has been in-
tensified.
Doctor Adkins, as is the case with each new
President, will bring his own ideas and objectives
into the picture, along with a commitment to
those already in place. He will add some
unique expertise in the field of business admini-
stration and management, a commodity most
significant in the light of current and prospective
economic conditions.
The Association has grown significantly with
Doctor Shannon’s dedication and intense desire
to serve its membership and the public of this
state. Positions relative to quality care and the
basic theme that the Association must exist first
for the good of the patient have been strength-
ened.
From the staff standpoint, and that of others
in the leadership, the year has been a most en-
joyable one. There might be some feeling of
frustration as to what didn’t quite get done,
but that in no way detracts from the overall
1982-83 record.
Linder Doctor Adkins’ leadership the member-
ship can feel comfortable that the same atmos-
phere of concern, dedication and intensity will
continue. The challenge to the membership will
be to respond to that leadership. We are confi-
dent it will.
As the American Medical Association recently
has noted, results of three separate polls related
to regulation and the jurisdiction of the Federal
Trade Commission over Medicine have contained
some interesting messages for the profession.
Among other things, the polls showed that the
public image of the AMA improved by two per
cent between 1981 and 1983,
PUBLIC TRUST with 72 per cent of the public
indicating a great deal or a fair
amount of confidence in the AMA’s ability to
propose fair and workable health policies.
Significantly, all other groups covered by the
surveys, including the federal government, con-
gressional committees and labor unions, reflected
declines in public confidence.
Most important, however, the polls showed an
increase in public preference for a local versus
national approach to the regulation of Medicine.
This preference had become a majority viewpoint
as of March of this year.
Along these same general lines, public opinion
also apparently had crystallized in favor of a
locally based approach to planning and develop-
ment of health care policies. This Lrend was
strongest among highly educated young people.
In earlier polls, the public view was somewhat
poorly defined when those surveyed were asked
if they had more confidence in policies de-
veloped by the government at the national level,
or by officials and groups at the local level.
This public expression of confidence in local
health planning and regulation can’t be stressed
too heavily in the face of the many forces and
trends at work today. Physicians in particular
are placed under even greater pressure to measure
up to what the public expects.
That’s why every effort and measure of sup-
port must be put forth to make agencies like the
West Virginia Board of Medicine viable, effec-
tive and credible organizations. Physicians,
in day-to-day dealings with individual patients
and the public in general, must have a keen
awareness of the trust and confidence placed in
them.
Professional and effective review programs
toward assurance of the highest quality of care
probably have never been more important. These
programs can be done best by doctors, and
should be so structured.
We never have suggested that there is a
particular or magic formula for such things as
patient rapport and professional conduct and
responsibility. Physicians know full well the
importance of such components which must be
a part of their practice.
But the heat, if you will, is on all professionals
in ever increasing degree. That’s obvious in
legislative halls, in the sprawling administrative
bureaucracy and anywhere else you might want
to look.
That’s why it is most encouraging to know
that the public still feels self-regulation of
physicians, rather than state or federal controls,
is best. This is a public trust that must be
accommodated. The alternatives are obvious,
and NOT in the best interest of patients and the
public.
168
The West Virginia Medical Journal
GENERAL NEWS
Congestive Heart Failure
Convention Subject
Dr. Warren T. Anderson, Morgantown cardi-
ologist. will speak on ‘‘The Management of Con-
gestive Heart Failure” during the 116th Annual
Meeting of the State Medical Association.
Doctor Anderson, Clinical Associate Profes-
sor of Cardiology at West \irginia University
School of Medicine,
will talk during a
“Symposium on Cardi-
ovascular Diseases”
which will constitute
the second general
scientific session on
Saturday morning,
August 27.
The convention will
be held August 25-27
at the Greenbrier in
White Sulphur Springs.
Warren T. Anderson, M. D. The announcement
of Doctor Anderson’s
paper by the Program Committee completes
arrangements for the combined business and
scientific event.
A recently-announced development, an innova-
tion this year, will be a black-tie dinner on
Saturday evening honoring outgoing and new
officers of the State Medical Association and
the Auxiliary. The “by-ticket only” dinner, the
final event in the three-day schedule, also is ex-
pected to be attended by the Presidents and
spouses of the American Medical Association
and neighboring states represented each year.
475 Expected to Attend
Some 475 physicians, spouses and others are
expected to attend the convention, with the
schedule to include: two sessions of the Associa-
tion’s House of Delegates; two general scientific
sessions; addresses by the AM A President, Dr.
Frank J. Jirka, Jr., of Barrington, Illinois, and
Dr. Samuel P. Asper of Philadelphia, President
of the Educational Commission for Foreign
Medical Graduates; a Saturday afternoon re-
ception for Association members and guests; and
the dinner Saturday evening, as noted.
There will be some 20 scientific exhibits for
viewing by conventioneers.
About 18 affiliated societies, sections and com-
mittees of the Association, and other medical
groups also will have business and scientific ses-
sions on Friday and Saturday, many in the form
of breakfast and luncheon meetings.
See the official program and related articles
in this issue of The Journal for specific conven-
tion activities and speakers.
Doctor Adkins to be Installed
Dr. Carl R. Adkins of Fayetteville, during the
second House session on Saturday, will be in-
stalled as Association President to succeed Dr.
Harry Shannon of Parkersburg.
Doctor Jirka will address the first House ses-
sion Thursday afternoon, and Doctor Asper will
Carl R. Adkins, M. D.
oi
fa
r'
ca
August, 1983, Vol. 79, No. 8
169
deliver the keynote Thomas L. Harris Address
during the opening exercises Friday morning.
The first general scientific session, a
“Symposium on Sexually Transmitted Diseases,”
will follow the opening exercises Friday morning.
The scientific session speakers, some of whom
also will give talks at the affiliated society and
section meetings, have been announced in pre-
vious issues of The Journal. As noted, they are
listed in the official program appearing in this
issue.
Doctor Shannon, a urologist, will deliver his
Presidential address at the second House session
on Saturday afternoon. Doctor Adkins, the in-
coming President, is in emergency medicine at
Raleigh General Hospital in Beckley.
Doctor Anderson came to Morgantown in
1977 from Washington, D.C., where he was
Clinical Instructor in the Department of Medi-
cine at Georgetown University (1971-77), and
completed a cardiology fellowship at Walter
Reed Army Medical Center (1971-73).
Certification
He is certified by the American Boards of
Internal Medicine and Cardiovascular Disease,
and is a Fellow of the American College of
Cardiology, American College of Physicians, and
Council of Clinical Cardiology.
Doctor Anderson was graduated from Virginia
Military Institute, and received his M. D. degree
in 1967 from Temple University. He served his
internship and residency at Letterman General
Hospital in San Francisco.
Convention Timetable
The first general scientific session will fol-
low 9 A. M. opening exercises on Friday,
August 26. The Saturday session will begin
at 9:30 A. M.
The first session of the House of Delegates
will be on Thursday afternoon, August 25,
beginning at 2:30. The second session will
be on Saturday afternoon beginning at 3:00.
Luncheon For Past Presidents
A luncheon honoring Past Presidents of the
West Virginia State Medical Association will
be held at the Greenbrier on Friday, August
26, d uring the 116th Annual Meeting.
Dr. John B. Markey of Charleston, immedi-
ate Past President, will preside, and invita-
tions have been extended to all the Associa-
tion’s Past Presidents.
The scientific exhibits, again to be housed in
Eisenhower Hall, will be open from 1 to 5 P. M.
on Thursday, and 8:30 A. M. to noon on Friday
and Saturday. The exhibits are listed elsewhere
in this issue of The Journal.
The Association’s Council will hold a pre-
convention meeting at 9:30 A. M. Thursday.
Dinner Tickets on Sale
Tickets for the Saturday evening dinner will
be on sale at the Association and Auxiliary
registration desks, beginning on Thursday
morning, August 25. It will be necessary to pro-
vide the Greenbrier with an attendance figure
by late on Friday, August 26.
The Annual Meeting of the Auxiliary to the
State Medical Association, with Mrs. Richard S.
Kerr of Morgantown the current President, as
usual will hold its meeting in conjunction with
that of the Association. The official Auxiliary
program also appears in this issue of The
Journal.
Nominating Committee To Meet
On Friday, August 26
The State Medical Association’s Committee
on Nominations will hold a 5 P. M. meeting
on Friday, August 26, in the Washington
Room of the Greenbrier.
Under a 1980 By-Laws amendment, the
Committee will submit to the House of
Delegates at least two nominees for the fol-
lowing offices: Vice President and Treasurer,
and Delegate and Alternate to the American
Medical Association. Only the name of one
nominee will be necessary for the President
Elect.
Association By-Laws also provide that
nominations may be made from the floor for
these offices, to be filled by the House in
balloting at its final session on Saturday,
August 27, the final day of the Association’s
116th Annual Meeting.
Dr. Stephen I). Ward of Wheeling will serve
as Chairman of the Committee on Nomina-
tions, with other members to include: Drs.
Antonio S. Licata of Weirton, Roland J.
Weisser, Jr., of Morgantown, Nabal B. Giron
of Romney, Cordell A. de la Pena of Clarks-
burg, John A. Mathias of Buckhannon, Joseph
T. Skaggs of Charleston and T. Keith Edwards
of Bluefield.
170
The West Virginia Medical Journal
Continuing Education
Activities
Here are the continuing medical education
activities listed primarily by the West Virginia
University School of Medicine for part of
1983, as compiled by Dr. Robert L. Smith,
Assistant Dean for Continuing Education, and
J. Zeb Wright, Ph. D., Coordinator, Con-
tinuing Education, Department of Community
Medicine, Charleston Division. The schedule is
presented as a convenience for physicians in plan-
ning their continuing education program. (Other
national, state and district medical meetings are
listed in the Medical Meetings Department of
The Journal. )
The program is tentative and subject to
change. It should be noted that weekly confer-
ences also are held on the Morgantown, Charles-
ton and Wheeling campuses. Further information
about these may be obtained from: Division of
Continuing Education, WVU Medical Center,
3110 MacCorkle Avenue, S. E., Charleston
25304; Office of Continuing Medical Education,
WVU Medical Center, Morgantown 26506; or
Office of Continuing Medical Education, Wheel-
ing Division, WVU School of Medicine, Ohio
Valley Medical Center, 2000 Eoff Street, Wheel-
ing 26003.
Sept. 3, Morgantown, Treatment Options in
Arthritis*
Sept. 9-10, Morgantown, Ob/Gyn Teaching
Days*
Sept. 14, Charleston, Advances in Hypertension
Sept. 16-17, Charleston. Advanced Trauma Life
Support Course
Oct. 1, Morgantown, Issues in Geriatric Medi-
cine*
Oct. 5, Charleston, Gastroenterology Update
Oct. 14, Ophthalmology Conference
Oct. 15, Morgantown, Common Problems in
Nephrology*
Oct. 28-29, Morgantown, Fourth Diagnostic
Ultrasound Conference
Oct. 29, Charleston, Oncology Seminar
Nov. 3-5, Morgantown, Ninth Annual Hal
Wanger Family Practice Conference*
Nov. 11-12, Morgantown, Fourth Sports Medi-
cine Symposium*
°Held in conjunction with WVU home football game.
August, 1983, Vol. 79, No. 8
Regularly Soiled uletl Continuing
Education Outreach Programs from
WVU Medical Center/
Charleston Division
Buckhannon, St. Joseph’s Hospital, first-floor
cafeteria, 3rd Thursday, 7-9 P. M. — Aug.
(summer break).
Cabin Creek, Cabin Creek Medical Center,
Dawes, 2nd Wednesday, 8-10 A. M. — Aug.
10, “Common Eye Emergencies,” Robert
O’Connor, M. D.
Cassaway, Braxton Co. Memorial Hospital, 1st
Wednesday, 7-9 P. M. — Aug. 3, “Diagnosis
of Pulmonary Disorders,” Dominic Gaziano,
M. D.
Madison, 2nd floor. Lick Creek Social Services
Bldg., 2nd Tuesday, 7-9 P. M. — Aug. 9,
“Approach to the Peripheral Vascular Pa-
tient,” Ali F. AbuRahma, M. D.
Oak Hill, Oak Hill High School (Oyler Exit, N
19) 4th Tuesday, 7-9 P. M. — Aug. (summer
break ) .
Welch, Stevens Clinic Hospital, 3rd Wednesday,
12 Noon-2 P. M. — Aug. (summer break).
IFhitesville, Raleigh-Boone Medical Center, 4th
Wednesday, 11 A. M.-l P. M. - — Aug. (sum-
mer break).
Williamson, Appalachian Power Auditorium, 1st
Thursday, 6:30-8:30 P. M. — Aug. (summer
break ).
Sept. 1, “Rational Use & Cost Containment in
Antibiotic Therapy” (speaker to be an-
nounced ).
Convention Exhibits Site
Eisenhower Hall
Members, spouses and others are urged to
view the scientific exhibits which will be on
display during the State Medical Association’s
116th Annual Meeting at the Greenbrier in
White Sulphur Springs.
The exhibits will be located in Eisenhower
Hall, on the Shop Floor and adjacent to the
theater. Exhibit hours will be from 1 to 5
P. M. on Thursday, August 25, and from 8:30
A. M. to noon on Friday and Saturday.
Coffee breaks during the scientific sessions
of the convention Friday and Saturday morn-
ings in the theater will be provided for visiting
the exhibits.
171
State Diabetes President
Dr. Bruce S. Chertow of Huntington recently
was elected President of the American Diabetes
Association, West Virginia Affiliate. Doctor
Chertow is Professor of Medicine and Chief,
Section of Endocrinology at Marshall University
School of Medicine.
Medical journals once belonging to Dr. lessee
Bennett, pioneer eighteenth century surgeon, are
displayed by Dr. John M. Grubb, obstetrician-gy-
necologist in Point Pleasant (Mason County). It is
reported that Doctor Bennett performed the first
cesarean section in America in Virginia in 1794. He
later moved to Mason County where he died and is
buried. The old journals were shown by Doctor
Grubb during a recent meeting of the Mason County
Medical Society in Point Pleasant.
‘Specialty For All Ages’ AAFP
Annual Meeting Theme
The Miami Beach Convention Center will be
the site of the 35th annual convention and
scientific assembly of the American Academy of
Family Physicians (AAFP) October 10-13.
Delegates from the West Virginia Chapter,
AAFP, will be Drs. F. Dale Simmons of Clarks-
burg and Joseph A. Smith of Dunbar.
This year’s theme, “Family Practice, a Spe-
cialty for All Ages,” highlights the family
physician’s capability of managing the entire
family’s health care.
Paul Harvey, radio, TV and newspaper com-
mentator, will keynote the scientific program at
1:30 P. M., Monday, October 10, at the Con-
vention Center.
Other lectures include “Fife Styles and
Stress,” “Acquired Immune Deficiency Syndrome
(AIDS),” and “Diet and Obesity.”
This year’s program offers 12 educational
activities and more than 100 practical topics
specifically designed to acquaint family physi-
cians with the latest medical advances. Some of
the topics are breast mass, fractures in children,
care and conditioning of the athlete, fetal
monitoring, and aspects of aging.
The Congress of Delegates, AAFP’s governing
body, will convene prior to the Assembly to con-
duct official business. The 112 delegates will
meet October 8-10 at the Fontainebleau Hilton,
Assembly headquarters.
Nearly 700 family physicians will receive the
degree of Fellow of the AAFP Tuesday, October
11, at the Theater of the Performing Arts in
Miami Beach.
Officers and Directors of the West Virginia Gastrointestinal Society were named at its annual meeting
held recently in Clarksburg. They are, from left, Drs. Sidney B. Jackson, Clarksburg, board member; Don-
ald E. McDowell, Morgantown, Secretary-Treasurer; Catalino B. Mendoza, Clarksburg, retiring President;
Duane D. VVebb, Huntington, President; Ronald D. Gaskins, Morgantown, President Elect; and William
O. McMillan, Jr., and Eric P. Mantz, both of Charleston, board members.
172
The West Virginia Medical Journal
State Medical Association Lists
Names of New Members
The following is a list by component societies of
new members of the West Virginia State Medical
Association elected from January 1 through June
30, 1983:
Boone
Ernest Yutiamco Madison
Brooke
Richard Bombach Wheeling
Cabell
Ijaz Ahmad
S. Ahmad Ettehadieh .
John P. Gearhart
Douglas Glover
Colette Gushurst
Roger G. Kimber, Jr.
Jayshri Mody
Alvaro Paz
Tully Roisman
Robert C. Touchon
C. Danny Waldrop
William E. Wheeler
Central West Virginia
Thomas La Mar Stahly... Summersville
Eastern Panhandle
Ronald J. Crisp..... Martinsburg
Edward E. Volcjak. “
Huntington
<(
Hamlin
Huntington
O. P. Gosien
Eleanor Navarro ..
Dante R. Oreta
Fayette
Oak Hill
Montgomery
- Charleston
Greenbrier Valley
Malcolm S. Harris .. Union
Thomas F. Mann Ronceverte
Dorris A. Ragsdale “
Lynn N. Smith “
Lois Speiden “
Haven N. Wall Lewisburg
Robert L. Wheeler Ronceverte
Harrison
Charles F. Chong Clarksburg
John J. Crossen “
Amar N. Gulati “
James A. Knost “
Saad Mossallati.... “
Susan W. Miller. .. “
Michael C. Robinson “
James Weinstein “
Raymond O. Rushden Charleston
Happy Verma
Maheshwer B. Verma
David Owen Wright —
Logan
Boppana Rao Prasada
Whitman
Marion
Agnes M. Franz — Fairmont
Sitha Rama Swamy Katragadda
Harry G. Kennedy, Jr “
Tom Turner. “
Marshall
Romeo Bihag Tan
Moundsville
Mason
Suresh Kumar Agrawal Point Pleasant
Mel P. Simon “
Richard L. Slack “
Mercer
R. M. Bhagat ............. Bluefield
Robert B. Miller .
John G. Murray, Jr. Cool Ridge
Charles M. Olmsted Bluefield
Stephen P. Poolos .. .... . —
Meryl A. Severson ~ Princeton
Mingo
Pastor C. Gomez Williamson
C. H. Yajnik “
Sutin Srisumrid South Williamson, KY
Subhash A. Vyas Williamson
Monongalia
Patricia Bayless
Priscilla Gilman
John P. Griffiths
Janis Leigh Hurst
Marian Swinker
Paul Parker Williams
Morgantown
u
Fairmont
Morgantown
Ohio
Vincente P. Almario..... Wheeling
Michael W. Blatt
Rajai T. Khoury. “
Donald John Mirate “
William L. Noble
Frederick J. Payne “
Ahmad Rahbar “
John Gregory Tellers “
Parkersburg Academy
Juanito Aya-Ay Grantsville
James Dauphin Parkersburg
Van B. Elliott
John Michael Foster
Purisima Guerrero “
R. B. Henthorn “
Richard Johns “
Jefferson
Michael R. P. Atherton. Ranson
John A. Stefano “
Kanawha
Antonio R. Cafoncelli.... Charleston
Stephen Paul Cassis “
Glenn Crotty, Jr. “
Paul H. Derboven Tornado
Kenneth M. Harman Charleston
Henry Levenson “
Robert Thomas Linger, Jr. “
Stephen E. Perkins South Charleston
Thomas Douglas Rapp..... ... Ripley
Potomac Valley
Henrv G. Tavlor
Franklin
Robert A. Gregg
Preston
Kingwood
Masontown
Patricia Haase
J. E. Swanton
Reedsville
Mario C. Ramas
Raleigh
Beckley
Cirilo Z. Villanueva
Tygart’s Valley
Robert M. Hollev
Clarksburg
Rex B. Kare
Robert W. O'Donnell..
Grafton
Elkins
(Continued On Next Page)
August, 1983, You. 79, No. 8
173
Student Members
R. David Allara .. .. WVU, Morgantown
John David Angotti .... WVU, Clarksburg
David R. Ayers MU, Huntington
Danny C. Blankenship WVU, Morgantown
A. Thomas Bundy “ “
Brent Wilson Chapman .. . “ “
Lee C. Drinkard.... WVU, Wheeling
Michael B. Edmond . WVU, Monongah
Jackson L. Flanigan MU, Martinsburg
Daniel Scott Frame .. - WVU, Morgantown
Jo Ann Goldbaugh “
Kimberly Carol Irwin “ “
Jocelyn L. James WVU, Charleston
Nancy Joseph MU, Huntington
Maurice D. Kinsolving ... ._ WVU, Morgantown
Susann Lea Lovejoy MU, Huntington
Michele Maroon WVU, Morgantown
Gary Lance Matheny WVU, Charleston
Mark Robert McGinnis WVU, Morgantown
Steven G. McLaughlin “ “
Kenneth F. McNiel MU, Huntington
William R. Marchand WVU, Morgantown
Debra Jean Panucci “ “
Lakshmikumar Pillai ... “
R. Michael Simpkins “
Teresa Lynn Skidmore “
Donna J. Slayton MU, Huntington
Elizabeth Spangler.. “ “
Gary Allen Thompson WVU, Morgantown
Richard K. Umstot, Jr. “ “
Richard M. Vaglienti “ “
Intern/Resident Members
Hasan Behdadnia Wheeling
Michael W. Burkhart Martinsburg
Richard A. Capito Charleston
Max A. Harned Wheeling
Douglas C. McCorkle Morgantown
Frank L. Schwartz “
Alfred Seco-Garcia Wheeling
1983 Roster Corrections
The following physicians have notified
headquarters staff of corrections in specialty
listings as they appear in the 1983 Roster of
Members of the West Virginia State Medical
Association:
• ■ o
Specialty
Society
Name
Change
Cabell
Frank Rivas
CD
Hancock
Timothy A. Brown
D
Harrison
Harry Bishop
R
Teodoro Medina
I-GF
Robert I. Mosenfeldei
• ObG
Jefferson
R. F. Rickel, Jr.
GP
Kanawha
Jerry Maliska
EM-GP
Joseph T. Skaggs
Adm
Monongalia
Charlene F. Horan
I
Parkersburg
Frederick C. Whittier
I-NEP
Academy
Anantrai Vora
Pd
Tygart’s
Valley
J udith A. Wolfe
OTO-A
Review A Book
The following books have been received by the
Headquarters Office of the State Medical Associa-
tion. Medical readers interested in reviewing any
of these volumes should address their requests to
Editor, The West Virginia Medical Journal, Post
Office Box 1031, Charleston 25324. We shall be
happy to send the books to you, and you may
keep them for your personal libraries after sub-
mitting to The Journal a review for publication.
General Ophthalmology, 10th Edition, by
Daniel Vaughan, M. D.; and Taylor Asbury,
M. D. 407 pages. Price $17. Lange Medical
Publications, Los Altos, California 94022.
1983.
Review of Medical Physiology, 11th Edition,
by William F. Ganong, M. D. 643 pages. Price
$20. Lange Medical Publications, Los Altos,
California 94022. 1983.
Handbook of Pediatrics, 14th Edition, by
Henry K. Silver, M. D.; C. Henry Kempe, M. D.;
and Henry B. Bruyn. M. D. 883 pages. Price
$13. Lange Medical Publications, Los Altos,
California 94022. 1983.
Handbook of Poisoning, 11th Edition, by
Robert H. Dreisbach, M. D. 632 pages. Price
$11. Lange Medical Publications, Los Altos,
California 94022. 1983.
The 1983 Program Committee
Chairman of the Program Committee for
the 116th Annual Meeting of the West Vir-
ginia State Medical Association is Dr. David
Z. Morgan of Morgantown. Other Committee
members are Drs. Jean P. Cavender of
Charleston, Michael J. Lewis of St. Marys,
Kenneth Scher of Huntington, Roland J.
Weisser of Morgantown, and Carl R. Adkins
of Fayetteville.
No Registration Fee for Members
Members of the West Virginia State Medical
Association will not be assessed a registration
fee for the 116th Annual Meeting at the
Greenbrier in White Sulphur Springs, August
25-27.
Interns, residents and medical students also
will be registered without charge.
There will be a registration fee of $75 for
out-of-state physicians attending the meeting.
174
The West Virginia Medical Journal
Auxiliary Completes Program
For 59th Annual Meeting
Mrs. John G. Bates of Cuthbert, Georgia, will
be among honored guests when the Auxiliary to
the West Virginia State Medical Association
holds its 59th Annual Meeting at the Greenbrier
in White Sulphur Springs August 25-27.
The meeting again will be held concurrently
with the Annual Meeting of the State Medical
Association. Mrs. Bates was installed in June as
the new President of the American Medical Asso-
ciation Auxiliary. She will deliver the keynote
address during the opening Auxiliary session
beginning at 9:30 A. M. on Friday, August 26.
Also addressing the Auxiliary will be Mrs.
William D. Hughes of Montgomery. Alabama,
President of the Southern Medical Association
Auxiliary.
More than 200 spouses of physicians are ex-
pected to attend the Auxiliary’s business sessions,
over which Mrs. Richard S. Kerr of Morgantown,
the Auxiliary’s President, will preside.
An invitation has been extended to all Aux-
iliary members to attend the first session of the
State Medical Association's House of Delegates
on Thursday, August 25, at 2:30 P. M. in Chesa-
peake Hall. Dr. Frank J. Jirka. Jr., AMA Presi-
dent, will be the principal speaker. Auxiliary
Mrs. Richard S. Kerr
Mrs. John G. Bates Mrs. William D. Hughes
members also are invited to attend formal open-
ing ceremonies of the Association’s 116th Annual
Meeting at 9 A.M. on Friday, August 26, in the
theater. Dr. Samuel P. Asper, President, Educa-
tional Commission for Foreign Medical Gradu-
ates, Philadelphia, will deliver the keynote
Thomas L. Harris Address.
Dr. Harry Shannon of Parkersburg, President
of the State Medical Association, will be recog-
nized for brief remarks prior to Mrs. Bates’
address Friday morning.
Mrs. Hughes will make her address during the
second general session Saturday morning. During
this session also, Mrs. Bates will install Mrs.
T. Keith Edwards of Bluefield as President, and
other new officers, and Mrs. Edwards will deliver
her inaugural address.
For other scheduled business and sports ac-
tivities, see the official Auxiliary program in
this issue of The Journal.
Doctor Fix Heads Organization
Of State Presidents
L. Walter Fix, M. D., of Martinsburg, Presi-
dent of the West Virginia State Medical Associa-
tion in 1980-81, assumed the Presidency of the
Organization of State Medical Association Presi-
dents at an annual business meeting in Chicago
in June.
OSMAP has a membership of current and past
presidents, and presidents-elect. of state medical
associations and societies. It is active in a num-
ber of endeavors, including presentation of
forums on medical affairs and other programs
held in conjunction with annual and interim
meetings of the American Medical Association’s
House of Delegates.
Doctor Fix first served as a member of
OSMAP's Steering Committee, and for the past
year has been President-Elect.
August, 1983, Vol. 79. No. 8
175
Convention Exhibit To Feature
Local Health Departments
Exhibits at, the West Virginia State Medical
Association’s August 25-27 Annual Meeting at
the Greenbrier will include one representing
stepped-up efforts to provide more information
for the medical community about local health
department activities.
L. Clark Hansbarger, M. D., West Virginia’s
Director of Health, said he will provide a display
of local health department activities and services,
along with material identifying local health
officers who serve throughout the state.
“I’m going to man that exhibit myself,”
Doctor Hansbarger said.
For the second year, the Annual Meeting pro-
gram will include a 1 P. M. session on Thursday,
August 25, in the Greenbrier’s Jackson Room
of state and local health officials to provide still
more ongoing dialogue and discussion. Other
physicians are invited to attend and participate
in this meeting.
Sports Events Again Planned
For Annual Meeting
Time will be at a premium, but physicians
and auxiliary members plan to work annual golf
and tennis competition into the tight business
and scientific program schedule for the State
Medical Association’s Annual Meeting at the
Greenbrier August 25-27.
Dr. William C Morgan of Charleston is the
defending champion in the Medical Golf Tourna-
ment. The women’s golf tournament was rained
out in 1982.
Winners of last year’s men’s doubles tennis
competition were Drs. Maurice A. Mufson of
Huntington and Jose Oyco of Beckley. Results
of the women’s tennis competition were not
available.
MU Graduate’s Paper Wins
Dr. Douglas W. Given, a 1983 graduate of the
Marshall University School of Medicine, pre-
sented the winning student research paper at the
Southern Health Association annual meeting in
June.
Doctor Given, a Strange Creek native, focused
on farming accidents.
Students from Marshall, West Virginia Uni-
versity and the University of North Carolina
presented papers at the Charleston meeting.
Medical Meetings
Aug. 1-3 — International Society for Sexually Trans-
mitted Disease Research, Seattle.
Aug. 1-5 — Am. Venereal Disease, Seattle.
Aug. 22-24 — Spinal Cord Regeneration & Recent De-
velopments (Am. Paraplegia Society), Las
Vegas.
Aug. 25-27 — 116th Annual Meeting, W. Va. State
Medical Assn., White Sulphur Springs.
Aug. 26 — W. Va. Chapter, Am. College of Emergency
Physicians, White Sulphur Springs.
Sept. 7-10 — Peripheral Vascular Disease Symposium
(Saint Anthony Hospital), Columbus, OH.
Sept. 29-Oct. 1 — Am. Assoc, for the Surgery of
Trauma.
Sept. 29-Oct. 2 — Am. Society of Internal Medicine,
San Francisco.
Sept. 30-Oct. 1 — W. Va. Chapter, Am. College of
Surgeons, Morgantown.
Oct. 2-5 — Am. Neurological Assoc., New Orleans.
Oct. 5-8 — Am. Thyroid Assoc., New Orleans.
Oct. 7-8 — AMA Congress on Occupational Health,
Beachwood, OH.
Oct. 16-21 — Am. College of Surgeons, Atlanta.
Oct. 22-27 — Am. Academy of Pediatrics, San Fran-
cisco.
Oct. 23-26 — Am. College of Gastroenterology, Los
Angeles.
Oct. 23-27 — Am. College of Chest Physicians,
Chicago.
Oct. 24-27 — Am. College of Emergency Physicians,
Atlanta.
Oct. 26-30 — Am. Academy of Child Psychiatry, San
Francisco.
Nov. 6-9 — Scientific Assembly, Southern Medical
Assoc., Baltimore.
Nov. 7-9 — Am. Medical Women’s Assoc., Dearborn,
MI.
Nov. 18-22 — Gerontological Society of Am., San
Francisco.
Nov. 30-Dec. 1 — Am. College of Chemosurgery,
Chicago.
1984
Jan. 19-21 — Neurosurgical Society of the Virginias,
Williamsburg, VA.
Jan. 27-29 — 17th Mid- Winter Clinical Conference,
Charleston.
Feb. 12-15 — W. Va. Perinatal Assoc., Snowshoe.
March 17 — Annual Meeting, W. Va. Affiliate,
American Diabetes Assoc., Wheeling.
176
The West Virginia Medical Journal
CONVENTION PROGRAM
116th ANNUAL MEETING
of the
West Virginia State Medical Association
THE GREENBRIER, WHITE SULPHUR SPRINGS
August 25-27, 1983
THURSDAY MORNING
August 25
(Eastern Daylight Time)
9:00-5:00 — Registration, Registration Lobby.
9:30 — Pre-Convention Meeting of the Council. John
B. Markey, M.D., Presiding (Fillmore
Room, with Luncheon in Tyler Room).
THURSDAY AFTERNOON
1:00 — Public Health-Local Health Officer Con-
ference (Jackson Room).
2:30 — First Session of the House of Delegates.
Harry Shannon, M.D., Presiding (Chesa-
peake Hall).
Invocation — Joe N. Jarrett, M.D.
Address: Frank J. Jirka, Jr., M.D., Presi-
dent, American Medical Association.
Recognition of AMA-ERF Grants to the
West Virginia University and Marshall
University Schools of Medicine.
Business Meeting.
5:00 — Committee on Resolutions. John J. Mahood,
M.D., Presiding (Directors’ Room).
FRIDAY MORNING
August 26
8:30-5:00 — Registration, Registration Lobby.
Breakfast Meetings
7:30 — Section on Internal Medicine. Maurice A.
Mufson, M.D., Presiding (Tyler Room).
Guest Speaker: George J. Pazin, M.D.
Subject: “Genital Herpes — Signs, Sex-
ual Relationships and Source Contacts
of Women with First-Time Disease.”
7:30 — Section on Dermatology. William A. Welton,
M.D., Presiding (Directors’ Room).
Case Presentations.
7:30 — Section on Surgery. Robert J. Reed III, M.D.,
Presiding (Pierce Room).
Guest Speaker: Alvin L. Watne, M.D.,
Professor and Chairman of Surgery,
West Virginia University School of
Medicine, Morgantown. Subject:
“Emergent Surgery for Acute Colicys-
titis.”
Opening Exercises
(Theater)
9:00 — Call to Order — Harry Shannon, M.D., Presi-
dent, West Virginia State Medical Asso-
ciation.
Invocation — Joseph T. Skaggs, M.D.
Address of Welcome — Harry Shannon,
M.D.
Introduction of David Z. Morgan, M.D.,
1983 Program Committee Chairman, and
other Members of his Committee.
“The Thomas L. Harris Address.”
Samuel P. Asper, M.D., President, Educa-
tional Commission for Foreign Medical
Graduates, Philadelphia, and Professor
of Medicine, The Johns Hopkins Univer-
sity, Baltimore. Subject: “Strengths and
Weaknesses of the U. S. Role in Inter-
national Medicine.”
First General Session
9:45-12:30
“Symposium on Sexually Transmitted
Diseases”
David Z. Morgan, M.D., Moderator
9:45 — Edmund C. Tramont, M.D., COL, MC, USA,
Chief, Infectious Diseases, Department of
Bacterial Diseases, Walter Reed Army
Institute of Research, Washington, DC.
Subject: “Syphilitic and Gonococcal In-
fections.”
August, 1983, Vol. 79, No. 8
177
10:15 — Lee P. Van Voids, M.D., Infectious Diseases
and Coordinator of Medical Education,
Department of Medicine, Hamot Medical
Center, Erie, Pennsylvania (formerly
Associate Professor of Medicine, Mar-
shall University School of Medicine,
Huntington). Subject: “Non - Luetic,
Non-Gonococcal Venereal Diseases.”
10:45 — Coffee Break to Visit Exhibits.
11:00 — George J. Pazin, M.D., Associate Professor of
Medicine, University of Pittsburgh
School of Medicine, Pittsburgh. Subject:
“Transmissible Diseases of the Gay Pa-
tient.”
11:30 — Jack L. Summers, M.D., Chairman, Depart-
ment of Urology, Akron City Hospital,
Akron, Ohio, and Professor of Urology,
Northeastern Ohio Universities College
of Medicine, Akron.
Subject: “Sexual Mores in the 1980s.”
12:00 — Questions, Answers and Discussion.
12:30 — Recess for Lunch.
FRIDAY AFTERNOON
12:30 — Luncheon Honoring Past Presidents of the
West Virginia State Medical Association.
John B. Markey, M.D., Presiding (Tyler
Room) .
12:30 — Cancer Committee. Business Meeting. Alvin
L. Watne, M.D., Presiding (Jackson
Room) .
12:30 — West Virginia Medical Institute, Inc., Board
of Trustees Meeting. Harry S. Weeks,
Jr., M.D., Presiding (Virginia Room).
1:00 — West Virginia Chapter, American College of
Emergency Physicians. Roger Frome,
M. D., Presiding (Pierce Room).
Guest Speakers: Warren T. Anderson,
M.D. Subject: “Update on Emergency
Cardiology.”
William E. Walker, M.D., Huntington.
Subject: “Update on Toxicology.”
1:00 — West Virginia State Neurosurgical Society.
Carrel M. Caudill, M.D., Presiding
(Buchanan Room).
Business meeting.
2:00 — West Virginia Chapter, American Academy
of Pediatrics. Kenneth L. Wible, M.D.,
Presiding (Fillmore Room) .
Guest Speakers: Karen A. Connors, Ph.D.,
Adjunct Assistant Professor of Pediatrics
and Infant Stimulation Specialist, West
Virginia University Affiliated Center for
Developmental Disabilities, Morgantown;
and Jan K. Nash, M.S.W., Developmental
Disabilities Coordinator, Valley Com-
munity Mental Health Center, Morgan-
town. Subject: “Enhancing the Coping
Strategies and Parenting Skills of Fam-
ilies with Developmental^ Delayed In-
fants.”
2:00 — Section on Orthopedic Surgery. Darrell C.
Belcher, M.D., Presiding (West Virginia
Room) .
Guest Speaker: Robert H. Cofield, M.D.,
Associate Professor, Mayo Medical
School; Consultant, Orthopedic Surgery,
Mayo Clinic, Rochester, Minnesota. Sub-
ject: “Management of Rotator Cuff Dis-
ease.”
2:00 — West Virginia District Branch, American
Psychiatric Association. Ralph S. Smith,
Jr., M.D., Presiding (Lee Room).
Guest Speakers: Armando R. Favazzo,
M.D,. Professor of Psychiatry, Univer-
sity of Missouri Medical Center, Colum-
bia. Subject: “Cultural Context of Self-
Mutilation.”
5:00 — Committee on Nominations. Stephen D.
Ward, M.D., Presiding (Washington
Room) .
FRIDAY EVENING
6:00 — Cocktail Party. The University of Virginia
Medical School Foundation. William C
Morgan, M.D., host (Old White Club).
6:00 — Cocktail Party. West Virginia Chapter,
Medical College of Virginia Alumni
Association. A. Thomas McCoy, M.D.,
in charge (Old White Club).
6:30 — Les Batards Reception. L. Walter Fix, M.D.,
in charge (Virginia Room).
6:30 — Cocktail Party. West Virginia University
Alumni Association. Richard A. DeVaul,
M.D., in charge (Spring Room).
SATURDAY MORNING
August 27
9:00-2:00 — Registration, Registration Lobby.
Breakfast Meetings
8:00 — Section on Urology. John A. Belis, M.D.,
Presiding (Jackson Room).
Guest Speaker: Jack L. Summers, M.D.
Subject: “Iridium 192 Therapy for
Carcinoma of the Prostate.”
8:00 — West Virginia Gastrointestinal Society.
Duane D. Webb, M.D., Presiding (Direc-
tors’ Room).
Guest Speaker: Doctor Webb. Subject:
“Hepatitis Vaccine and Antigens.”
8:00 — West Virginia Radiological Society. Johnsey
L. Leef, Jr., M.D. Presiding (Lee Room).
Guest Speaker: Peter Armstrong, M.D.,
Professor and Vice Chairman, Depart-
ment of Radiology, University of Vir-
ginia, Charlottesville. Subject: “Radi-
ology of Diffuse Lung Disease.”
178
The West Virginia Medical Journal
Second General Session
(Theater)
9 : 30 - 12:15
“Symposium on Cardiovascular Diseases”
Moderator: Jean P. Cavender, M.D.
9:30 — John C. Alexander, Jr., M.D., Chief, Section
of Cardiothoracic Surgery, West Virginia
University School of Medicine, Morgan-
town. Subject: “Cardiovascular Sur-
gery — An Update.”
10:15 — Stafford G. Warren, M.D., Clinical Professor
of Medicine, WVU Charleston Division.
Subject: “New Developments in the
Management of Cardiac Arrhythmias.”
11:00 — Coffee Break to Visit Exhibits.
11: 15 — Warren T. Anderson, M.D., Clinical Associate
Professor of Cardiology, West Virginia
University School of Medicine, Morgan-
town. Subject: “The Management of
Congestive Heart Failure.”
12:00 — Questions, Answers and Discussion.
12:15 — Recess for Lunch.
SATURDAY AFTERNOON
12:00 — Publication Committee. Stephen D. Ward,
M.D., Presiding (Jackson Room).
12:00 — West Virginia State Society of Anesthesio-
logists. Jeanne A. Rodman, M.D., Pre-
siding (Directors’ Room) .
Guest Speaker: John C. Alexander, Jr.,
M.D. Subject: “Problems in Anes-
thesia Unique to Cardiovascular Sur-
gery.”
3:00 — Second and Final Session of the House of
Delegates. Harry Shannon, M.D., Pre-
siding (Chesapeake Hall).
Invocation — Robert D. Hess, M.D.
Presidential Address: Harry Shannon,
M.D.
Presentation of New Officers of Auxiliary
to the West Virginia State Medical
Association.
Presentation of Honor Guests.
Business Meeting.
Election of Officers.
Installation of Carl R. Adkins, M.D., Fay-
etteville, as President of the West Vir-
ginia State Medical Association.
SATURDAY EVENING
7:00 — Reception for West Virginia State Medical
Association Members and Guests (Chesa-
peake Terrace).
8:00 — Dinner Honoring Officers of the West Vir-
ginia State Medical Association and
Auxiliary (Chesapeake Hall).
August, 1983, Vol. 79, No. 8
179
A WORD OF THANKS
The 1983 Program Committee, and the officers and members of the West Virginia
State Medical Association, wish to acknowledge with sincere thanks grants received
from the following firms to help support the Scientific Program for this year’s
1 16th Annual Meeting.
CIBA PHARMACEUTICAL COMPANY
Northeastern Region
King of Prussia, PA
GEIGY PHARMACEUTICALS
Kingston, PA
HOECHST-ROUSSEL PHARMACEUTICALS, INC.
Somerville, NJ
HOSPITAL & PHYSICIANS SUPPLY COMPANY
Charleston, WV
ELI LILLY AND COMPANY
and DISTA PRODUCTS COMPANY
Indianapolis, IN
PARKE-DAVIS
DIVISION OF
WARNER-LAMBERT COMPANY
Morris Plains, NJ
A. H. ROBINS COMPANY
Richmond, VA
WILLIAM H. RORER, INC.
Fort Washington, PA
ROXANE LABORATORIES, INC.
Columbus, OH
SMITH KLINE & FRENCH LABORATORIES
Philadelphia, PA
THE UPJOHN COMPANY
Kalamazoo, MI
(The firms listed above are those which had allocated funds to the Scientific Program as this issue
of the The Journal went to press. Additional contributors will be listed in the Official Program to be
distributed at the Greenbrier.)
180
The West Virginia Medical Journal
DELEGATES AND ALTERNATES
BOONE (2) — Delegates, Robert B. Atkins and
Manuel T. Uy, Madison. Alternates, Sriramloo
Kesari and Probhond Chinuntdet, Madison.
BROOKE (2) — Delegates, Rogelio L. Velarde,
Follansbee; and Richard Bombach, Wheeling. Alter-
nates, Leticia Peralta-Velarde, Follansbee; and W.
T. Booher, Jr., Wellsburg.
CABELL (14) — Delegates, Stephen K. Wolfe, Jack
Leckie, Charles E. Turner, Robert R. Dennison, Jr.,
William L. Neal, Tara Sharma, John D. Harrah, Earl
J. Foster, John Gearhart, M. Bruce Martin, Joseph
B. Touma, Robert W. Lowe, Winfield C. John and
S. Bruce Chandor, Huntington. Alternates, Hossein
Sakhai, Jose I. Ricard, Robert L. Bradley, Thomas F.
Scott, Roy A. Edwards, Jr., N. G. Baranetsky and
Gary G. Gilbert, Huntington; W. W. Mills and
H. S. Mullens, Kenova; K. V. Raman, John A. Hunt,
W. F. Daniels, Jr., Kenneth Scher and Seyed H.
Hadi-Sadegh, Huntington.
CENTRAL WEST VIRGINIA (3) — Delegates,
Joseph B. Reed, Buckhannon; Alfred J. Magee, Sum-
mersville; and Greenbrier Almond, Buckhannon.
Alternates, John A. Mathias, Buckhannon; and
Frank A. Scattaregia, Weston.
EASTERN PANHANDLE (4)— Delegates, Fran-
cisco D. Sabado, Jr., John S. Palkot, L. Walter Fix
and George C. Soteropoulos, Martinsburg. Alter-
nates, C. Vincent Townsend, Robert S. Strauch, R. J.
Estogoy and Edward P. Quarantillo, Jr., Martins-
burg.
FAYETTE (3) — Delegates, Joe N. Jarrett and
Serafino S. Maducdoc, Jr., Oak Hill; and Rolando
C. Ramirez, Montgomery. Alternates, Honorato M.
Aguila and Chuan H. Lee, Oak Hill; and Adin L.
Timbayan, Montgomery.
GREENBRIER VALLEY (4)— Delegates, Stephen
L. Sebert, Fairlea; Romeo R. Ednacot, Ronceverte;
Harvey A. Martin, White Sulphur Springs; and
Charles E. Weinstein, Ronceverte. Alternates, Robert
K. Modlin, Benjamin L. Plybon, Lynn N. Smith and
Robert L. Wheeler, Ronceverte.
HANCOCK (4) — Delegates, Pedro R. Montero, Jr.,
Chester; Timothy A. Brown, Antonio S. Licata and
Thomas J. Beynon, Weirton.
HARRISON (7) — Delegates, James E. Bland,
James Genin, Joseph D. Wright, John A. Bellotte,
Erlinda L. de la Pena, Clarksburg; Sidney B. Jack-
son, Bridgeport; and Robert D. Hess, Clarksburg.
Alternates, Louis C. Palmer, Bridgeport; Chinmay
K. Datta, Cordell A. de la Pena, George W. Shehl,
T. H. Chang and David A. Lynch, Clarksburg.
JEFFERSON (2) — Delegate, L. Mildred Williams,
Charles Town. Alternate, S. K. G. Menon, Ranson.
KANAWHA (21)— Delegates, Alberto G. Capin-
pin, Charleston; W. Alva Deardorff, South Charles-
ton; Donald E. Farmer, Robert L. Ghiz, Carl B.
Hall, Echols A. Hansbarger, Jr., Sherman E. Hat-
field, Charleston; George W. Hogshead, Nitro; James
W. Lane, K. G. MacDonald, Sr., Tony Majestro,
Jimmy L. Mangus, John B. Markey, Lionel Nair,
Robert B. Point, Warren Point, Charleston; Richard
C. Rashid, South Charleston; William C. Revercomb,
Jr., Charleston; Carl J. Roncaglione, South Charles-
ton; and George A. Shawkey and Joseph T. Skaggs,
Charleston. Alternates, Adla Adi, Clinton A. Briley,
Jr., William H. Carter, Robert James Clubb, George
V. Hamrick, Fred F. Holt, Thomas J. Janicki, Alberto
C. Lee, Rogelio T. Lim, Eric P. Mantz, William O.
McMillan, Jr., William C Morgan, Jr., Pejawar M.
Rao, William G. Sale, Richard H. Sibley, Charles-
ton; Joseph A. Smith, Dunbar; and George E. Tomas,
Alfredo C. Velasquez, Charles C. Weise, Ronald L.
Wilkinson and John F. Zeedick, Charleston.
LOGAN (4) — Delegates, Chanchai Tivitmahaisoon,
Logan; Thomas P. Long, Man; Herbert D. Stern,
Logan; and Enrico V. Rallos, Gilbert. Alternates,
Subhash Bhanot, West Logan; Carlos F. DeLara,
Logan; Noor Laynab, Whitman; and Alberto M.
Garma, Logan.
MARION (4) — Delegates, Babu R. Devabhakthuni,
Jack S. Koay, Guy David Leveaux, Mack I. Mc-
Clain and Stanard L. Swihart, Fairmont. Alternates,
Michael A. Grant, Chi Meen Lee, David M. McLellan,
William L. Mossburg and P. Kent Thrush, Fairmont.
MARSHALL (3) — Delegates, Carlos C. Jimenez,
Kenneth J. Allen and Carl L. Anderson, Glen Dale.
Alternate, Jose J. Ventosa, Jr., Glen Dale.
MASON (2) — Delegates, Richard L. Slack and
Aarom Boonsue, Point Pleasant. Alternate, Mel P.
Simon, Point Pleasant.
McDOWELL (3) — Delegates, John S. Cook, Rich-
ard O. Gale and Louis A. Vega, Welch. Alternates,
Bernard M. Swope, Vernon J. Magnus and Arthur
Allen Carr, Welch.
MERCER (7) — Delegates, David F. Bell, Jr., and
J. E. Blaydes, Jr., Bluefield; Mario Cardenas and
Frank J. Holroyd, Princeton; John J. Mahood, Blue-
field; William Prudich, Montcalm; and Edward M.
Spencer, Bluefield.
MINGO (3) — Delegates, Edward B. Headley, Del-
barton; Nikhanth Purohit and Diane E. Shafer, Wil-
liamson. Alternate, C. H. Yajnik, Williamson.
MONONGALIA (15) — Delegates, Donald C. Car-
ter, Ralph W. Ryan, George A. Curry, Eric T. Jones,
J. David Blaha, A. Hugh Lindsay, David Z. Morgan,
Robert L. Smith, Herbert E. Warden, Roland J.
Weisser, Jr., Orlando F. Gabriele, William A. Neal,
August, 1983, Vol. 79, No. 8
181
Martha D. Mullett, Richard S. Kerr and J. W. Kessel,
Morgantown. Alternates, James G. Arbogast, Robert
Bettinger, K. Douglas Bowers, Jr., Thomas S. Clark,
Thomas W. Crosby, Anthony G. Di Bartolomeo, John
L. Fullmer, R. Brooks Gainer II, Frank C. Griswold,
Paul J. Jakubec, Michael T. Hogan, Roger E. King,
Lawrance S. Miller and Alvin L. Watne, Morgan-
town.
OHIO (10) — Delegates, George E. Bontos, Robert
S. Robbins, James C. Durig, D. L. Latos, Milton E.
Nugent, Robert J. Reed III, M. D. Reiter, Stephen
D. Ward, Harry S. Weeks, Jr., and D. Verne Mc-
Connell, Wheeling.
PARKERSBURG ACADEMY (8) — Delegates,
Michael J. Lewis, St. Marys; Billie M. Atkinson,
Parkersburg; Logan W. Hovis, Vienna; and Paul
W. Burke, William E. Gilmore, John E. Beane and
Robert F. Gustke, Parkersburg.
POTOMAC VALLEY (3)— Delegates, Jeffrey S.
Life, Romney; and Paul T. Healy and James C.
Bosley, Keyser. Alternates, Suratkal V. Shenoy and
Robert W. McCoy, Jr., Keyser.
PRESTON (2) — Delegates, Patricia Haase, Mason-
town; and Thomas A. Haymond, Reedsville. Alter-
nates, John W. Trenton, Kingwood; and William H.
Harriman, Jr., Terra Alta.
RALEIGH (8) — Delegates, Norman W. Taylor,
Jose L. Oyco, Michael T. Webb, Nancy R. Webb,
Worthy W. McKinney, William D. McLean, William
C. Covey, Jr., and A. Allen Bliss, Beckley. Alter-
nates, S. L. Francis, Lamberto C. Maramba, Isidro
G. Zarsadias, Jr., Iligino Salon, Mario C. Ramas,
Prospero B. Gogo, Richard D. Richmond, and T.
Rosal Rojas, Jr., Beckley.
SUMMERS (2) — Delegate, Eduardo L. Jimenez,
Hinton. Alternate, Chandra P. Sharma, Hinton.
TYGART’S VALLEY (6) — Delegates, Karl J.
Myers, Jr., Philippi; Gene W. Harlow, Grafton;
Michael M. Stump V, Elkins; Halberto G. Cruz,
Philippi; and Jerome C. Arnett, Jr., and Hugh H.
Cook, Jr., Elkins. Alternates, Robert R. Rector and
James B. Magee, Elkins; Samuel M. Santibanez,
Grafton; Mary E. Myers, Philippi; and Melanio D.
Acosta, Jr., Parsons.
WESTERN (3) — Delegates, Herminio L. Gam-
ponia, Spencer; James T. Hughes and Ali H. Morad,
Ripley.
WETZEL (2) — Delegates, Donald A. Blum and
K. M. Chengappa, New Martinsville.
WYOMING (2) — Delegates, Frank J. Zsoldos and
Ross E. Newman, Mullens.
Reception Committee
Frank J. Holroyd
Harry S. Weeks, Jr.
Harry Shannon
David Z. Morgan
Carl R. Adkins
George A. Shawkey
Stephen D. Ward
Robert R. Weiler
Joseph A. Smith
Carl J. Roncaglione
Jack Leckie
Thomas F. Scott
Robert D. Hess
Roger E. King
Worthy W. McKinney
Sherman E. Hatfield
John B. Markey
Arthur A. Abplanalp
John J. Mahood
William E. Gilmore
L. Walter Fix
John A. Mathias
Norman W. Taylor
Joseph J. Renn III
Charles C. Weise
Joseph T. Skaggs
D. L. Latos
George W. Hogshead
Jean P. Cavender
George A. Curry
John A. Bellotte
Richard S. Kerr
David B. Gray
Robert R. Rector
Diane E. Shafer
Catalino B. Mendoza, Jr.
Herbert D. Stern
L. Mildred Williams
Warren Point
Charles E. Turner
Cordell A. de la Pena
182
The West Virginia Medical Journal
Official Program
AUXILIARY
to the
West Virginia State Medical Association
59th Annual Meeting
THE GREENBRIER
White Sulphur Springs
August 25-27, 1983
THURSDAY AFTERNOON
August 25
2:00-5:00 — Registration, Lower Lobby.
2:30 — First Session of the House of Delegates, West
Virginia State Medical Association
(Chesapeake Hall).
Address by Frank J. Jirka, Jr., M. D., Presi-
dent, American Medical Association.
Recognition of AMA-ERF Grants to the
We9t Virginia University and Marshall
University Schools of Medicine.
4:00 — Pre-Convention Board Meeting, Mrs. Richard
S. Kerr, President, presiding (Fillmore-
Van Buren Rooms).
FRIDAY MORNING
August 26
9:00-4:00 — Registration, Lower Lobby.
8:00— Past Presidents’ Breakfast, Mrs. Logan W.
Hovis, Immediate Past President, presid-
ing (Virginia Room).
9:30 — Formal Opening of the Convention, Mrs.
Richard S. Kerr, President, presiding
(Fillmore-Van Buren Rooms).
Invocation, Pledge of Loyalty and Pledge
to Flag.
In Memoriam — Mrs. G. A. Shawkey.
Introduction of Honored Guests.
Presentation of Harry Shannon, M. D.,
President, West Virginia State Medical
Association.
Introduction of Convention Chairman —
Mrs. Logan W. Hovis.
Roll Call of Delegates — Mrs. Charles C.
Weise, Recording Secretary.
Declaration of a Quorum — Mrs. J. L. Man-
gus, Parliamentarian.
Keynote Address — Mrs. John G. Bates,
President, American Medical Association
Auxiliary.
Credentials and Registration — Mrs. Wilson
P. Smith.
Convention Rules of Order — Mrs. J. L.
Mangus, Parliamentarian.
Report of the 1982 Convention Reading
Committee.
Treasurer’s Report — Mrs. Harvey Reisen-
weber.
Recommendations from Pre - Convention
Board Meeting.
New Business.
Report of the 1983 Nominating Committee,
First Reading — Mrs. Logan W. Hovis.
Election of the 1984 Nominating Commit-
tee.
Reports of Officers and Chairmen of Stand-
ing Committees. (Those published in the
Annual Reports Book will not be read.)
Presentation of Regional Directors (and
two-minute reports by county presi-
dents ) :
Northern Region — Mrs. A. S. Licata.
Eastern Region — Mrs. Thomas W.
Crosby.
Western Region — Mrs. Mario Cardenas.
Southern Region — Mrs. William M.
Jennings.
Central Region — Mrs. Jose M. Serrato.
Announcements.
Door Prizes — Mrs. Frank J. Holroyd.
Recess.
FRIDAY AFTERNOON
Bridge (Trellis Lobby). Host Auxiliary,
Eastern Panhandle, Mrs. Harvey D.
Reisenweber.
Golf. Host Auxiliary, Kanawha County,
Mrs. John B. Markey.
Tennis. Host Auxiliary, Raleigh County,
Mrs. Prospero B. Gogo.
(Times to be announced).
SATURDAY MORNING
August 27
9:00-10:00 — Registration, Lower Lobby.
9:00 — Second General Session, Mrs. Richard S. Kerr,
President, presiding (Fillmore-Van Buren
Rooms) .
Introduction of Honored Guests.
August, 1983, Vol. 79, No. 8
183
Roll Call of Delegates — Mrs. Charles C.
Weise.
Declaration of a Quorum — Mrs. J. L. Man-
gus, Parliamentarian.
Address — Mrs. William D. Hughes, Presi-
dent, Southern Medical Association Aux-
iliary.
Convention Announcements — Mrs. Logan
W. Hovis.
Credentials and Registration — Mrs. Wilson
P. Smith.
Presentation of AMA-ERF Awards — Mrs.
Herman Fischer, Chairman. Recognition
of AMA-ERF Grants to the West Virginia
University and Marshall University
Schools of Medicine.
Unfinished Business.
Report of the 1983 Nominating Committee,
Second Reading — Mrs. Logan W. Hovis.
Election of Officers.
Installation of Officers — Mrs. John G.
Bates, President, American Medical Asso-
ciation Auxiliary.
Presentation of President’s Pin and Gavel,
Mrs. Richard S. Kerr.
Presentation of Past President’s Pin, Mrs.
Logan W. Hovis.
Inaugural Address — Mrs. T. Keith Edwards.
Announcements.
Door Prizes.
Adjournment.
11:00 — Post-Convention Board Meeting — Mrs. T.
Keith Edwards, President, presiding (Fill-
more-Van Bureau Rooms).
SATURDAY AFTERNOON
Presidential Address: Harry Shannon,
M. D.
Installation of Carl R. Adkins, M. D.,
Fayetteville, as 1983-84 President of the
West Virginia State Medical Association.
(Auxiliary members are invited and urged
to attend).
SATURDAY EVENING
7:00 — Reception for State Medical Association mem-
bers and guests (Chesapeake Terrace).
8:00 — Dinner honoring officers of the West Virginia
State Medical Association and the Aux-
iliary (Chesapeake Hall).
3:00 — Second and Final Session of the House of
Delegates, West Virginia State Medical
Association (Chesapeake Hall).
184
The West Virginia Medical Journal
SCIENTIFIC EXHIBITS
AMERICAN DIABETES ASSOCIATION,
WEST VIRGINIA AFFILIATE, INC.
“DIABETES.” Information on the work and goals
of the group.
Mike Murray, Affiliate member, and Douglas L.
Jones, M. D., member, Board of Directors.
BUREAU OF VENEREAL DISEASE CONTROL,
WEST VIRGINIA STATE HEALTH DEPARTMENT
“SEXUALLY TRANSMITTED DISEASES.” The
two-panel display features one of the prominent
sexually transmitted diseases. Current STD man-
agement materials are available for pick-up by
medical professionals. In addition, representatives
from the West Virginia Venereal Disease Program
will be manning the exhibit to discuss the state pro-
gram and address other inquiries concerning the
STDs.
Ronald Bryant, Director, Venereal Disease Pro-
gram, and Gregory Moore and Alan Bernstein,
Venereal Disease Field Representatives.
CHARLESTON AREA MEDICAL CENTER AND
AUXILIARY TO CAMC MEMORIAL DIVISION
“CAMC EXHIBIT.” The exhibit will contain
CAMC educational and informational materials, in-
cluding copies of a physician’s referral brochure,
photographs of CAMC, and a slide/tape show on
the medical center.
Joseph T. Skaggs, M. D., Director of Medical
Affairs; and William B. Ferrell, Assistant to Execu-
tive Vice President.
“TEL-MED” (AUXILIARY). Tel-Med, a free
health information program, is a library of taped
telephone messages on a variety of health and
health-related subjects that have been approved and
endorsed by the CAMC medical staff and Kanawha
Medical Society. To use Tel-Med, dial the local
number, 343-4400 (Charleston area) or the toll-free
number outside of Charleston, 1-800-352-6510, and
request the tape of your choice. Operating hours are
from 9 A. M. to 8 P. M. six days a week, and from
1 to 4 P. M. on Sundays and holidays.
Frances McMillan, Health Education Chairman.
DEPARTMENT OF MEDICINE, MARSHALL
UNIVERSITY SCHOOL OF MEDICINE
“IMPACT OF VIRAL RESPIRATORY DISEASES
ON INFANTS AND YOUNG CHILDREN IN A
RURAL AND SUBURBAN AREA OF SOUTHERN
WEST VIRGINIA.” Acute viral respiratory disease
occurring in children in Huntington, West Virginia
(urban children), or in the hollows surrounding
Huntington (rural children) was evaluated from
September, 1978, through March, 1980. Epidemics
of illnesses occurred simultaneously in the urban
and rural groups. Among both the urban and rural
ambulatory children, adenoviruses were the most
common viruses isolated, and respiratory syncytial
virus was the second most common viral pathogen
isolated. Among the urban and rural hospitalized
children, respiratory syncytial virus was the most
common virus isolated. The risk of hospitalization
because of respiratory disease was found to be one
in every 20 children during the first four years of
life, and the estimated risk of hospitalization be-
cause of respiratory syncytial virus infection was
one in 30.
Maurice A. Mufson, M. D., Chairman.
DISABILITY DETERMINATION SERVICE,
WEST VIRGINIA DIVISION OF
VOCATIONAL REHABILITATION
“EVALUATION OF DISABILITY FOR SOCIAL
SECURITY: HEMATOLOGY/ONCOLOGY, PE-
DIATRICS AND ORTHOPEDICS.” Three board
certified physicians wall present video tapes on
difficult aspects of reporting for independent medi-
cal assessment: Hematology /Oncology, A. Rafael
Gomez, M. D., Charleston; Pediatrics, Marcel G.
Lambrechts, M. D., Charleston, and Orthopedics,
Robert W. Lowe, M. D., Huntington.
These presentations also should aid attending
physicians in preparing their abstracts for Social
Security.
David H. Cleland, Medical Relations Officer.
FAMILY MEDICINE FOUNDATION OF
WEST VIRGINIA
(WEST VIRGINIA CHAPTER, AMERICAN
ACADEMY OF FAMILY PHYSICIANS)
“FUND RAISER— SEIGLE PARKS, M. D.” The
Foundation will have on display three paintings by
Seigle Parks, M. D., one of our family physicians.
Doctor Parks donated these paintings for a fund
raiser to benefit the Foundation. Please stop by our
exhibit where these paintings will be on display.
We also will have information on the long-term and
short-term goals of the Foundation.
Robert D. Hess, M. D., President; Thomas P. Long,
M. D., Trustee, and Chris Ferrell.
NATIONWIDE INSURANCE— MEDICARE
“MEDICARE OPERATIONS.” Nationwide invites
you to stop by and discuss your Medicare problems.
Find out about CPT-4 coding and our electronic
media claims billing available to your offices. Learn
how you can receive payments faster.
James A. Cuppy, Electronic Media Claims Man-
ager; James B. Irwin, Field Service Manager, and
Betty Rickenbacker, West Virginia Field Manager.
SOUTHERN MEDICAL ASSOCIATION
“SOUTHERN MEDICAL ASSOCIATION.” South-
ern Medical will have information available on the
August, 1983, Vol. 79, No. 8
185
advantages of membership such as continuing medi-
cal education-Dial Access, regional postgraduate
conferences, leadership seminars, medical malprac-
tice seminars, the annual scientific assembly, and the
Southern Medical Journal. Also available will be
material on financial benefits to members such as
the IRA, Keogh Plan, retirement and insurance
programs, research project fund, and loans and
scholarships.
Robert P. Mosca, Director, Member Services, and
Marc B. Wilson, Sales Coordinator.
STATE MEDICAL ASSOCIATION’S GROUP
INSURANCE AND PROFESSIONAL
LIABILITY PLANS
McDonough Caperton Shepherd Group, managing
general agent of the State Medical Association’s
group insurance and professional liability plans, will
have on hand information describing each of the
programs officially endorsed by the Association.
Representatives also will be available to answer
questions about the plans available.
Mike Costello and Tom Auman, representatives.
JOHN TAYLOR, M. D.
“MANAGEMENT OF RECURRENT BASAL CELL
EPITHELIOMA.” Some aspects of the etiology,
morphology and photobiology of basal cell carci-
nomas are treated. A discussion concerning the dif-
ferent treatment modalities available is given and
the advantages and disadvantages of each pointed
out. Metastasizing basal cell carcinoma is discussed.
Three cases of multiply recurrent basal cell carci-
noma causing extensive debility and multiple
ablative attempts are demonstrated. A recommenda-
tion for definitive surgical excision utilizing either
frozen section control or the Mohs technique is
made, particularly in the recurrent lesions or those
of a morpheaform or ulcerative invasive growth
pattern.
John Taylor, M. D., Bluefield, West Virginia.
U. S. ARMY MEDICAL DEPARTMENT
“U. S. ARMY MEDICAL DEPARTMENT.” Career
opportunities as a member of the Army Medical
Department, U. S. Army Reserve.
Major James E. Kuza and Major Sheila Bowman,
USAR AMEDD Procurement Counselors, and Cap-
tain David Royer, USA AMEDD Procurement Coun-
selor.
U. S. NAVY RECRUITING DISTRICT,
LOUISVILLE, KENTUCKY
“COMPUTER-ASSISTED MEDICAL DIAGNOSIS
OF ABDOMINAL PAIN.” We will present a video-
tape demonstration of our system for computer-
assisted medical diagnosis of abdominal pain. The
system currently is undergoing sea trials aboard
approximately 100 submarines.
HMC William Brandshagen, USN, and HM1 Ken
Devore, USN.
WEST VIRGINIA DEPARTMENT OF HEALTH
“YOUR LOCAL HEALTH DEPARTMENT.” This
is a display of local health department activities and
services as well as a highlight of local health officers
in each county.
L. Clark Hansbarger, M. D., Director.
WEST VIRGINIA DIVISION OF VOCATIONAL
REHABILITATION AND WEST VIRGINIA
WORKERS’ COMPENSATION FUND
“JOINT VOCATIONAL REHABILITATION-
WORKERS’ COMPENSATION PROGRAM.” The
exhibit features a three-screen audiovisual presen-
tation that describes the program for persons injured
on the job, a program operated jointly by the West
Virginia Division of Vocational Rehabilitation and
the West Virginia Workers’ Compensation Fund.
Side panels of the exhibit treat in detail the services
provided by the two agencies.
Samuel B. Mann, Lewisburg District Supervisor,
DVR; and Thomas Lyttleton, Rehabilitation Coun-
selor, Lewisburg Office, DVR (Workers’ Compensa-
tion representatives to be named).
WEST VIRGINIA MEDICAL INSTITUTE, INC.
“WEST VIRGINIA MEDICAL INSTITUTE, INC.
— DRG DISPLAY.” The exhibit will display infor-
mation on classification by Diagnosis Related Groups
(DRGs). An on-line CRT terminal will be available
for accessing selected DRG data from WVMI’s data
base for Medicare and Medicaid patients. In addi-
tion, samples of hard-copy DRG reports by hospital
and physician will be available. WVMI staff and
physician committee members will attend the dis-
play.
WEST VIRGINIA PERINATAL ASSOCIATION
“WEST VIRGINIA PERINATAL ASSOCIATION.”
This exhibit will announce the formation of a new
organization which will improve health care to
pregnant women and newborns. The organization
is multidisciplinary, including obstetricians, pedia-
tricians and family practitioners.
Martha D. Mullett, M. D., President.
WEST VIRGINIA
PHYSICAL THERAPY ASSOCIATION
“PEDIATRIC REHABILITATION: CURRENT
CONCEPTS OF CARE.” The display is designed to
depict current concepts in pediatric rehabilitation.
Emphasis is on informing physicians of the changing
roles and responsibilities of the physical therapy
practitioner.
Dee-dee Daniel and Hugh Murray, physical ther-
apists.
WEST VIRGINIA POISON CENTER
“GET TO KNOW ABOUT POISONS.” Describes
the various functions of, and materials available to,
the professional and lay public through the West
Virginia Poison System.
Terri DeFazio, Susie Aston, Sheila Totten, Donna
Samples, and Cynthia Tennant, poison specialists.
186
The West Virginia Medical Journal
WEST VIRGINIA UNIVERSITY HOSPITAL
“WEST VIRGINIA UNIVERSITY HOSPITAL
TODAY!” The exhibit illustrates some of the tech-
nologies available to referring physicians and their
patients. Vascular specialists screen patients with
noninvasive procedures for hemodynamically signifi-
cant carotid artery stenosis. Angioplasty to open
narrowed or occluded blood vessels is the cardi-
ologist’s newest tool. Surgical specialists use lasers
for cutting and vaporization of tissue. Neonatal life
support continues to increase in sophistication. 1-125
implantations are used to treat cancer of the prostate
and pancreas. Radiologists enjoy more refined
images of the malfunctioning kidney with per-
cutaneous procedures. Spend a few minutes to see
“West Virginia University Hospital Today!”
David Fine, Administrator; Andrew Lasser, Asso-
ciate Administrator, and Virginia Nugent, Adminis-
trative Assistant.
WEST VIRGINIA UNIVERSITY
SCHOOL OF MEDICINE
“WEST VIRGINIA UNIVERSITY SCHOOL OF
MEDICINE REACHES OUT.” Because the WVU
School of Medicine exists “for the sake of West
Virginians,” every department is involved in activ-
ities which purposely extend beyond the campus
boundaries. This exhibit portrays many examples
of programs designed to reach out and make a direct,
practical difference for individuals and communities
across West Virginia. Examples range from edu-
cating MDs who will establish their practice in West
Virginia communities, to hearing clinics for the
elderly, to genetics screening programs for pros-
pective parents, and to providing orthopedic con-
sultation at a home for handicapped children.
Robert L. Smith, M. D., Assistant Dean, School of
Medicine; Linda C. Morningstar, Consultant, School
of Medicine, and Robert E. Kristofco, Manager,
CME, School of Medicine.
August, 1983, Vol. 79, No. 8
187
ANNUAL REPORTS
Committee on Insurance
The year 1983 marks the 35th of the West
Virginia State Medical Association’s Insurance
Program. Since its establishment in 1948,
hundreds of doctors throughout West Virginia
have been the recipients of benefits under this
program.
Throughout the years, each plan has been
continuously upgraded and new plans added to
meet the needs of our members. Two examples
would be the following:
Major Medical Plan — As reported last year,
the Committee approved our insurance ad-
ministrator’s recommendation to change in-
surance companies and expand benefits under
this plan. As a result, the number of partici-
pants lias increased from 206 to 328.
Life Plan — Within the past year, partici-
pation in this plan lias increased by 25 per
cent.
In addition to tbe above, our members con-
tinue to avail themselves of the following plans
which comprise our total insurance portfolio:
Income Protection ( Disability )
Accidental Death & Dismemberment
Hospital Indemnity Plan
Office Overhead Expense
Coordinated Pension Services
Professional Liability Insurance (separate
report attached )
Summarization
Our total insurance program available to mem-
bers and their employees continues to provide a
very viable benefit for members of tbe West Vir-
ginia State Medical Association. Since 1948, it
has stood the test of time with the continuous
support of our members and the professional
competence of our administrator.
Professional Liability
The Professional Liability Insurance Program
is a combination of effort on the part of the
M edical Association, CNA Insurance Company
and McDonough Caperton Shepherd Association
Group to provide a first-rate professional liability
program for eligible Association members.
Common representation of all physicians in
the program by the Managing General Agent -
the role occupied by McDonough Caperton Shep-
herd — is important for program responsiveness.
Provision exists for West Virginia physicians to
be important contributors in claim review and
peer review. Physicians are given an opportunity
to be heard concerning any element of the pro-
gram.
Several accomplishments for the program
need to be reported:
1. A new computer program that rates and
prints tbe policies in Charleston is func-
tional.
2. A new computer claim program that pro-
vides statistical data for loss control efforts
now exists.
3. The District Claim Review Panels are
functional.
4. The Professional Evaluation Committee
has provided input in several areas of con-
cern.
5. Several loss control programs have been
presented to medical groups.
The Association-endorsed program is currently
in sound condition. This will continue as long
as physicians work to support the program. This
includes providing medical input into the pro-
cess of selecting insured physicians. The Associ-
ation wants the selection process to be fair, but
feels strongly that physicians with repeated poor
loss experience or evidence of improper practices
should not be insured in the program. The pro-
gram must remain financially healthy. This is
an area in which strength in numbers is im-
portant. We encourage all members to review
the CNA program and see the commitment being
made to West Virginia Medicine.
Respectfully submitted,
Jack Leckie, M. D., Chairman
Committee on Medical Education
and Hospitals
The past year (September to August) has
produced considerable activity on the part of the
West Virginia State Medical Association’s Com-
mittee on Medical Education and Hospitals.
Since the early 1970s, this Committee has
been the unit to execute Association responsi-
bility for the accreditation of intrastate con-
188
The West Virginia Medical Journal
tinuing medical education programs, primarily
at community hospitals. In its role, the Associa-
tion has been an arm of various national organ-
izations, including the American Medical As-
sociation; the Liaison Committee on Continuing
Medical Education, and now the multi-organiza-
tion Accreditation Council for Continuing Medi-
cal Education.
This past year has seen Committee representa-
tives and members of the Association staff re-
survey for continued accreditation CME pro-
grams at Charleston Area Medical Center,
Broaddus Hospital-Myers Clinic in Philippi, and
the West Virginia Academy of Ophthalmology.
In each instance, varying periods of additional
accreditation resulted.
Surveyed as a new applicant for accreditation
was City Hospital of Martinsburg — given initial,
provisional approval. Being processed as this
report was prepared was another new application
from United Hospital Center in Clarksburg,
while the year also will bring resurveys at Jack-
son Ceneral Hospital in Ripley, Veterans Ad-
ministration Center in Martinsburg, Ohio Valley
Medical Center /Wheeling Hospital, St. Francis
Hospital in Charleston and Northern Panhandle
Mental Health Center in Wheeling.
New Surveys
New surveys usually are conducted by an on-
site team of two or three persons, with one mem-
ber an Association staff representative, after
completion by the organization being surveyed
of a detailed questionnaire setting forth CME
budgets, assigned administrative and education
responsibilities, methods for evaluation of course
material, etc. The new surveys are always con-
ducted while a CME activity is in session.
A similar questionnaire is required in a resur-
vey, usually involving a one-physician site visit
in which, among other things, a careful review
is made of progress — including correction of
previously noted defects — made in the preceding
accreditation period.
First a subcommittee and then the full Com-
mittee on Medical Education and Hospitals are
involved in a review of accreditation team find-
ings and recommendations before the institutions
or organizations are advised of the action taken.
Accreditation can and should mean many things
to facilities and physicians, including approval
of CME programs for Category 1 credit toward
the AMA Physician’s Recognition Award.
This past year also has brought detailed review
and comment by key Committee representatives,
and the Association staff, on an all-but-final, and
extensive, revision of the national essentials for
accreditation of those institutions sponsoring
CME programs. Essentials used in West Virginia
are consistent with — and in some instances go
a bit beyond — the national standards.
Also revised and strengthened this year has
been the ACCME-developed protocol for recogni-
tion of state medical associations and/or
societies as accrediting agencies for intrastate
CME. The West Virginia State Medical Associa-
tion can look forward in the near future to a
visit from an ACCME team to determine how
the Association is meeting the protocol criteria.
Pre-Survey Questionnaire
Such a visit will be preceded by a pre-survey
questionnaire which must be completed and re-
turned in time for full review by an ACCME
representative prior to the actual site visit.
Working relationships with the national
ACCME office in the Chicago area have been
most satisfactory and productive. The Associa-
tion was charged by its leadership, in the early
1970s, with developing a fair but demanding
program for intrastate accreditation.
The road, over the years, has not been with-
out growth problems and rough spots. In some
instances, accreditation of institutions initially
has been denied, or provisional approval re-
moved. But the overall results appear solid and
effective.
The commitment to the program is, if any-
thing, stronger than ever, particularly in the light
of the new essentials and protocol. That leads
to a further confidence that the physician, staff
and other investment not only is justified, hut
ranks as one of the most valuable services the
Association can provide.
Respectfully submitted,
William 0. McMillan, Jr., M. D., Chairman
Cancer Committee
The Cancer Committee met at the State Medi-
cal Association’s Annual Meeting at the Green-
brier on August 27, 1982, and again in Charles-
ton on January 23, 1983, during the 16th
Mid-Winter Clinical Conference.
The State Cancer Registry was explored again,
and again recommended for re-establishment. It
was noted that cancer has been designated as a
reportable disease.
The American Cancer Society’s Caring and
Sharing and Cancer Prevention programs con-
August, 1983, Vol. 79, No. 8
189
tinue to be successful throughout the state, and
are endorsed by the Committee.
The Community Clinical Oncology Program
Grant for West Virginia was submitted. Dr.
Steven J. Jubelirer, the principal investigator at
Charleston Division of West Virginia University
Medical Center, has been notified of its approval
and funding.
Fifteen new Cancer Liaison members of the
American College of Surgeons were appointed
by Doctor Watne, and others will continue to he
appointed.
Respectfully submitted,
Alvin L. Watne, M. D., Chairman
Committee on Venereal Disease
The incidence of venereal disease in West
Virginia for calendar year 1982 totalled 3,211
cases occurring in every county of the state.
Case-related data revealed a level of 160 infec-
tions per 100,000. Gonorrhea represented 2,609
cases or a rate of 130 per 100,000. The inci-
dence of venereal disease in West Virginia is
most evident among the age group 15-29, which
reportedly represented 80 per cent of the
morbidity.
Other sexually transmitted diseases that are
being observed frequently by practitioners are
non-gonococcal urethritis/vaginitis and herpes
simplex Type II. While NGU can be and is
easily treatable, herpes is not. Increased inci-
dence of these diseases as well as acquired
immune deficiency syndrome (AIDS), which
seems to be most prevalent nationally in the gay
community but certainly involves other social
and health-problem groups, may be a basis for
future consideration to make these diseases
reportable in West Virginia.
The statewide culture screening activity
directed toward early detection of asymptomatic
female gonorrhea victims provided 54,950 ex-
aminations in 1981-82; 804 young women of
child-bearing age were found to have laboratory
evidence of the disease. With this in mind,
medical providers should consider strongly per-
forming routine cervical gonorrhea cultures on
females 15-40 years of age when doing pelvic
workups, particularly in all prenatal patients both
early as well as late in their pregnancy.
Inquiries regarding the medical/epidemiologic
management of the sexually transmitted diseases
can be addressed through a toll-free line within
the state venereal disease program, 1-800-642-
8244, or by calling your local health department.
Respectfully submitted,
Page H. Seekford, M. D., Chairman
190
The West Virginia Medical Journal
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ROUTE 60, WEST ST. ALBANS 722-4900
WVU Medical Center
-News—
Compiled from material furnished by the Medical Center
News Service, Morgantown, W. Va.
School Of Medicine Faculty
Promotions Announced
Twenty-five faculty members in the School of
Medicine have been awarded promotions.
John E. Jones, WVU Vice-President for JJealth
Sciences, announced the promotions which were
approved by the West Virginia Board of Regents
along with 22 others from the University Medical
Center's three other schools.
Each school makes performance reviews
based on teaching, research and service before
the promotions recommendations are sent to the
hoard.
Those promoted, effective July 1, in the School
of Medicine were:
Soad Bekheit, Professor, Medicine; J. David
Blaha, Associate Professor, Orthopedic Surgery;
Eric Brestel, Associate Professor, Medicine;
David B. Burr, Associate Professor, Anatomy;
J. Richard Casuccio, Assistant Professor, Oto-
laryngology; Paul L. Clausell, Associate Profes-
sor, Behavioral Medicine and Psychiatry; Joseph
Fontana, Associate Professor, Medicine; David
F. Graf, Associate Professor, Anesthesiology;
Marybeth JJarris, Assistant Professor, Physical
Therapy; Richard J. Head, Associate Professor,
Pharmacology and Toxicology; Ellen Hrabovsky,
Professor, Surgery; Michael Johnson, Associate
Professor, Physiology.
Steven Jubelirer, Associate Professor, Medi-
cine; Arthur E. Kelley, Associate Professor, Be-
havioral Medicine and Psychiatry; Darshan S.
Kelley, Research Assistant Professor, Biochemi-
stry; Richard E. Klabunde, Associate Professor,
Physiology; Rolf F. Kletziem, Professor, Bio-
chemistry; William W. Orr, Associate Professor,
Behavioral Medicine and Psychiatry; John
Petronis, Professor, Physical Therapy; Patrick
Robinson, Associate Professor, Medicine; Joan
T. Robison, Associate Professor, Behavioral
Medicine and Psychiatry; Jamshid Tehranzadeh,
Associate Professor, Radiology; George Try-
fiates, Professor, Biochemistry; Irma EHlrich.
Professor, Medicine; Mary J. Wimmer, Associ-
ate Professor, Biochemistry.
Use Of Laser Unblocks Airway
In Lung Cancer Patient
Uaser treatment to unblock the right main air-
way of a patient suffering from lung cancer has
been used at WVU Medical Center with good
results.
Drs. Harakh Dedhia and N. LeRoy Lapp, co-
investigators, said that to their knowledge it was
the first use in West Virginia of Nd-YAG laser
phototherapy in lung cancer.
Doctor Dedhia is Associate Professor of
Anesthesiology and Medicine, and Doctor Lapp
is Professor of Medicine and Chief of the
Pulmonary Medicine Section.
They said the patient had complete blockage
of the right main bronchus where it joins the
windpipe, and that the radiotherapists didn’t
want to treat the lung cancer because of the
obstruction.
Faced Dilemma
“They felt they would either give too heavy
a dose of radiation to the collapsed lung or would
induce infection behind the obstruction, and
she would be worse off than she was,” Doctor
Lapp explained.
“So they asked us to see if we could open
that passage and give her some air in the right
lung, which we were able to do in three treat-
ments.
“After each treatment, we gave the patient a
period of time to heal. When we looked at the
treated area there was evidence of sloughing off
of all black, dead tissue, and there was a smooth
membrane covering the area, so there was some
healing which had occurred as well.”
Doctor Lapp cautioned, however, that the
treatment is experimental and is limited to use
in selected patients for whom surgery is not indi-
cated.
The West Virginia Medical Journal
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• Individualized treatment
• A fully accredited school
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George T. Harding, Jr., M.D.
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Third-Party News, Views
and Program Concerns
FTC Okays Preferred Provider
Group In New Jersey
In its first pronouncement on the subject, the
Federal Trade Commission has given its tenta-
tive blessing to a proposed preferred provider
organization ( PPO ) in New Jersey.
The advisory does not have the weight of law,
and is not binding on courts, though courts do
consider advisory opinions. It could be revoked
at any time. In addition. PPOs have taken many
forms, and clearance for the New Jersey PPO is
not applicable to other types of PPOs.
The advisory is significant, however, in that it
represents the FTC’s first step into the cloudy
issues surrounding the PPO concept, the Ameri-
can Medical Association commented.
The advisory that was issued went to Health
Care Management Associates (HCMA), a
Moorestown, New Jersey, consulting firm that is
developing a PPO known as the Cooperating
Provider Program. It said the FTC does not be-
lieve HCMA’s proposed PPO would violate anti-
trust law.
HCMA Is Brokering Agent
HCMA sees itself as a brokering agent in the
arrangement. It would contract with up to 15
per cent of individual physicians, oral surgeons,
podiatrists and psychologists in three counties
to provide care to patients covered under the
plans of insurers or companies that sign up with
HCMA.
In its advisory letter to HCMA, the FTC noted
that “no actively practicing provider, hospital, or
payer has any direct or indirect financial, con-
trolling, or non-controlling interest in HCMA.”
It also carefully spelled out that the financial ar-
rangements are to be between HCMA and each
individual physician.
Those, according to FTC official Walter Wins-
low, are two aspects of HCMA’s plan that set it
apart from many other PPOs. The latter is
particularly significant because it distinguished
HCMA from the Maricopa Foundation in
Arizona, which the Supreme Court ruled had
engaged in price fixing by agreeing jointly on
the maximum fees its members would seek.
FTC Also Approves Review
Of Private Programs
The FTC also gave a Rhode Island Profes-
sional Standards Review Organization the go-
ahead for its plan to review the medical necessity
of care provided to private employers’ health
benefits programs.
The PSRO had asked the FTC in January for
an advisory opinion on its plan to conduct pre-
admission and concurrent reviews of private pa-
tients, to recommend appropriate lengths of hos-
pital stays and to conduct quality review studies.
Its recommendations are not binding on the
companies, and no fee reviews would be con-
ducted under the program.
4 Baby Doe’ Rule Springs
Back To Life
The U. S. Department of Health and Human
Services has proposed a new version of the con-
troversial “Baby Doe” rule requiring hospitals
and clinics to post, notices publicizing a 24-hour
hotline to be used in cases of suspected neglect.
The original regulation was struck down in
federal court last May.
The procedure, rather than the substance of
the rule, is changed. It still contains the re-
quirement to post notices listing the hotline num-
ber. But instead of requiring the posting of the
notice in delivery, maternity, and intensive care
wards, it requires that the notice must be posted
in nursing stations. The new rule also will allow
a longer public comment period.
The rule’s long preamble and appendix specify
that federal law “does not require the imposition
of futile therapies which merely temporarily pro-
long the process of dying of an infant born
terminally ill.” The rule also attempts to define
the term “handicap” as disorders such as “mental
retardation, blindness, paralysis, deafness, or lack
of limbs.”
“Any judgment that a person is not worthy of
treatment due to such handicap is not ... a
medical judgment, even if made by doctors . . . ,”
the rule says.
xiv
The West Virginia Medical Journal
Obituaries
SANGA TANTULAVANICH, M. D.
Dr. Sanga Tantulavanich. Welch internist, was
drowned on April 2 after heavy seas capsized the
boat in which he was a passenger in the Gulf of
Thailand.
Doctor Tantulavanich, 33, was one of eight
persons drowned or originally missing in the
accident; 22 others were rescued. The site was
near the coastal city of Samut Prakan in
Thailand.
A native of Bangkok, Thailand, Doctor
Tantulavanich was a member of the staff of
Stevens Clinic Hospital in Welch.
He was a member of the McDowell County
Medical Society and the West Virginia State
Medical Association.
County Societies
FAYETTE
Dr. Sidney Richman of Hartford, Connecticut,
was the guest speaker for the meeting of the
Fayette County Medical Society on June 1 at
Montgomery General Hospital.
Doctor Richman’s topic was “The Use of
Beta-Blockers in Hypertension.” He is a
cardiologist and Associate Professor of Medi-
cine at the University of Connecticut. — S. S.
Maducdoc, Jr., M. D., Secretary-Treasurer.
CHANGE OF ADDRESS
Members of the West Virginia State Medical
Association are requested to notify the headquarters
offices promptly concerning any change in address.
The 1984 Roster of Members will be prepared and
placed in the mails shortly after the first of the year
and we would very much like for your correct ad-
dress to appear in same. If applicable, to comply
with recent U. S. Postal Service regulations, please
include your P. O. Box number with zip code.
Changes should be mailed to Box 1031, Charleston,
West Virginia 25324.
The
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included in course materials.
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For information, contact:
Continuing Education
The Milton S. Hers hey
Medical Center
P.O. Box 851
Department 4006
Hershey, PA 17033-0851
(717) 534-6495
August, 1983, Vol. 79, No. 8
xv
Professional
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Reprinted from The West Virginia Medical Journal, September 1981
Your Association’s Professional Liability Insurance Program Includes:
• A market guarantee with Continental Casualty Company,
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The West Virginia Hedical Journal
Vol. 79, No. 9
September, 1983
Public Health Legacy of the Vietnam War:
Post-Traumatic Stress Disorder and Implications
for Appalachians*
DANIEL SUMROK, B. A.
Marshall University School of Medicine Student,
Class of 1984, Huntington
STEVEN L. GILES, Ph.D.
Team Leader,
Huntington Veterans Center
MILDRED MITCHELL-BATEMAN, M. D.
Professor and Former Chairman of Psychiatry,
Marshall University School of Medicine
Suicide ; child and spouse abuse ; divorce;
alcoholism and drug abuse; jail terms, and
psychiatric and physical maladies are the public
health legacy of the Vietnam War. Complex
interacting factors account for the fact that West
Virginians suffered the highest casualty rates
during the war. It is conservatively estimated
that 7,000 West Virginians continue to suffer
from Post-Traumatic Stress Disorder ( PTSD ) in
the aftermath of the war. The temptation has
been for Americans to want to forget our longest
war — one that ue lost. It is a painful story.
If providers of medical and health care are
to intervene successfully in this mammoth public
health problem, the dynamics of its development
must be understood.
Introduction
'"pms paper is intended to explain the problems
presently being experienced by some Viet-
nam veterans. It is an attempt to heighten the
awareness of primary care providers and their
colleagues so that the public can be better served.
“This paper was developed in conjunction with a special
research project conducted through the Marshall Uni-
versity School of Medicine’s Department of Psychiatry.
Approximately 8.5 million individuals served
in the military during the Vietnam era with 2.8
million being assigned to Southeast Asia from
1964 - 1973. Almost one million were engaged
in active combat or w r ere exposed to hostile,
life-threatening situations (President’s Commis-
sion on Mental Health, 1978). There are 29,000
Vietnam combat veterans in the state of West
Virginia (Giles, 1981). A major problem has
been to convince the public, both lay and profes-
sional. that Vietnam veterans indeed experienced
a war that was unique in its situations and
stresses. The nature of the Vietnam struggle has
presented a unique set of problems to those who
experienced it. Herein, it is hoped that the
reasons for the uniqueness, and as such, the toll
exacted on our countrymen and their families
and friends can be clarified.
Just as defending our great nation is every-
one’s responsibility, so is it everyone’s responsi-
bility to recognize the defenders, their sacrifices,
and provide them the sensitive treatment they
need.
Combat as Stress:
A Review of the
Development of Current Theory
During World War I, specific clinical
syndromes came to be associated with combat
duty. Previously, such casualties had been dis-
missed as being a result of cowardice and poor
discipline. The concept evolved that the high
pressure of exploding shells caused actual
physiologic damage precipitating symptoms la-
beled “shell shock.” By the end of the war, the
September, 1983, Vol.. 79, No. 9
191
syndrome was being described as a “war
neurosis” (Glass, 1969). As with any neurosis,
the focus was that predisposing personality
characteristics of the combatant were responsible
for the reaction, rather than the traumatic ex-
periences intrinsic to combat.
In the early years of World War II, psychiatric
casualties had increased by 300 per cent com-
pared to World War I, even though preinduction
psychiatric rejection rate was four times greater
than World War I (Figley, 1978). At one point
in the war, the number of men being discharged
from service for psychiatric reasons actually
exceeded the number of men being drafted
( Tiffany /Allerton, 1967).
Using the assumption that predispositional
factors were the primary precipitant of combat
psychological breakdown, it soon became appar-
ent that not many soldiers would be immune. In
fact, a 1944 Inspector General’s report con-
cluded: “If screening is to weed out all those
likely to develop a psychiatric disorder, then all
should be weeded out.” The concept of war
neurosis with an etiolgic basis on the pre-military
history of combatant had outlived its usefulness.
Hereafter, various intrinsic combat stresses were
recognized as the basis of psychiatric decompen-
sation (Figley, 1978).
The lessons of World War II were well
learned. Due to the efforts of military psychi-
atrist Alber Glass (1954), combatants who suf-
fered breakdown in Korea were dealt with in a
very situational and usually on-site manner, with
the expectation of speedy return to the combat
unit. The results of the new perspective had
immediate payoffs. During World War 11, 23
per cent of casualties evacuated suffered from a
psychiatric malady whereas only 6 per cent of
Korean War casualties were evacuated for
psychiatric reasons (Bourne, 1970).
Suprisingly, in the Vietnam War, battlefield
psychological casualties evolved in a new and
unexpected direction. What was expected via
past war experience (and what was prepared
for) did not materialize. Battlefield psycho-
logical casualties were at an all time low of 1.2
per cent (Bourne, 1970). At the time it was
thought that the use of preventive measures
learned in Korea and added situational manipu-
lations (to be discussed later) had solved the
ancient problem of combat breakdown.
As the war continued for a number of years,
some trends began to emerge. A previously
obscure but well documented phenomenon of
World War II began to be seen again. At the
end of World War II, some men suffering from
acute combat reaction, as well as their peers
with no such symptoms, began to report common
complaints, such as intense anxiety, battle
dreams, depression, explosive agressive behavior,
and problems with interpersonal relationships.
These symptoms were found in five-year follow-
up (Futterman and Pumpian-Mindlin, 1951)
and 20-year follow-up studies (Archibald and
Tuddenham, 1965).
Again in Vietnam, both those who had suffered
from acute combat reaction and others who did
not began to claim these same symptoms long
after leaving the combat situation. What was
unusual compared to previous wars was the
large number of veterans reporting these symp-
toms. In previous wars, incidence of psychiatric
casualties was observed to increase as intensity
of the war increased, and correspondingly, the
incidence decreased as the war intensity de-
creased. During Vietnam the pattern of reported
psychiatric casualties differed; as combat in-
tensity increased, there was no corresponding
increases in the casualty rate. It was not until
the early 70s, as the war was winding down, that
incidence of psychiatric disorders began to in-
ii On state-by-state analysis , West Vir-
ginians suffered the highest casualty rate
in Vietnam ivith 85 men losing their life
for every 100,000 males in the 1970
census
crease. By 1973, with the end of direct American
troop involvement, the number of veterans pre-
senting with neuropsychiatric disorders mush-
roomed ( President’s Commission on Mental
Health, 1978).
During the 1970s, many civilian natural
disasters had occurred (fires, earthquakes, plane
crashes, etc. ) . The survivors of these catas-
trophies presented with problems strikingly
similar to those of Vietnam veterans. After
much research (Figley, 1978) by various
veterans’ task forces and recommendations by
therapists involved with civilian post-traumatic
problems, the Diagnostic and Statistical Manual
III ( DSM III), published in 1980, included a
new category: Post-Traumatic Stress Disorder
(Acute, Chronic and/or Delayed).
The acute subtype can be thought of as those
disorders previously known as “shell shock” or
“acute combat reaction.” As noted, the incidence
of this acute type, due to behavioral manipula-
tions and unique circumstances of the Vietnam
War, was very low. The chronic or delayed sub-
192
The West Virginia Medical Journal
types have, however, taken on special significance
with their recognition in veterans of the Vietnam
War. PTSD (Delayed or Chronic) manifests
itself in various insidious processes, and often
may have been diagnosed as an individual
personality disorder.
Features of Post-Traumatic Stress Disorder,
Chronic or Delayed
Characteristic symptoms follow a psycho-
logically traumatic event outside the range of
usual human experiences (DSM III, 1980).
Simple bereavement, chronic illness, business
losses or marital conflict are considered within
the usual realm of experience unlike rape or
assault, military combat, natural disasters,
serious car or plane accidents, torture or concen-
tration camps.
PTSD can be variously expressed. Commonly
the individual suffers intrusive, painful recollec-
tions or nightmares during which the stressful
event is re-experienced. Rarely, dissociative
states, lasting minutes to hours or days, occur
during which the individual relives, and behaves
as if experiencing, the original stressful event.
Diminished responsiveness to external events
referred to as “emotional anesthesia” or “psychic
numbing” commonly begins soon after the stres-
sor event. PTSD victims complain of feeling
detached or estranged from previously significant
life experiences (DSM III, 1980). Problems with
intimacy, tenderness and sexuality are common.
In fact, the majority of veterans at the Hunting-
ton Vet Center are experiencing marital diffi-
culty (Giles, 1981). Many report this is a
consequence of loss of affect, which they them-
selves relate to Vietnam combat experience.
Exaggerated startle response or hyperalertness
due to hyperautonomia follow the stressor.
Phobic avoidance of situations that remind
victims of the stressor is common. Hot, humid
weather, helicopter noise, open spaces in fields
surrounded by thick vegetation and “annivers-
ary” reactions have been reported to stimulate
exacerbation of symptoms. Anxiety and depres-
sion, explosive behavior with minimal or no
provocation, inability to concentrate, and failing
memory are all characteristic. Substance abuse
and its milieu of accompanying complicating
effects often develop.
The Vietnam Experience as Predisposing to
Post-Traumatic Stress Disorder
Going into Vietnam, military planners used
lessons of previous wars in an attempt to solve
the huge problem of battlefield psychological
breakdown. It was understood that men with the
most combat exposure suffered the highest rate
of breakdown.
The result was the DERO$ system (date of
expected return from overseas). All personnel
knew upon leaving the United States when he or
she would be rotated back stateside. All tours
were 12 months except those for the Marines,
who served 13 months. DEROS offered each
individual a way out of the war other than as a
physical or psychological casualty (Kormos,
1978). The advantage of the system was clear.
If the individual could hold together for the
predesignated time period, the promise of state-
side rotation would be a way for the combatant
to leave the war behind. The disadvantages of
DEROS were not immediately clear. DEROS
became a very personal thing as each person
rotated on his own with his own specific date.
This meant that the Vietnam experience became,
for each person, a solitary, individual episode.
It was rare, after the first few years of the war,
for entire units to be sent to the war zone simul-
taneously. As Bourne noted (1970, p. 12),
“The war becomes a highly individualized,
encapsulated event for each man. His war begins
the day he arrives in the country and ends the
day he leaves.” Bourne further asserts (p. 42),
“He feels no continuity with those who precede
or follow him. He even feels apart from those
who are with him but rotating on a different
schedule.”
Unit morale, cohesion and identification suf-
fered tremendously (Kormos, 1978). Studies
from past wars ( Grinker & Spiegel, 1945) point
to unit integrity acting as a buffer for the indi-
vidual against the overwhelming stresses of com-
bat. World War II veterans commonly spent
extended periods of weeks or months on “the
long boat ride home.” The importance of this
is that the World War II veterans, in the context
of the unit, were able to work through especially
troubling combat experiences that they had been
through together. In contrast, the Vietnam
veteran had a solitary plane ride home and a
head full of grief, joy, confusion and conflict.
Many went from firefight to southern California
in a period of 36 hours. Most made it stateside
in less than one week.
For the Vietnam combatant the DEROS date
became a fantasy that promised an end to all
problems as he took the “freedom bird” state-
side. In the “other world” context of Vietnam,
individuals believed that neither they as indi-
viduals, nor the United States as a society, had
changed in their absence. Hundreds of thousands
September, 1983, Vol. 79, No. 9
193
lived this daily fantasy as evidenced by the uni-
versal popularity of “short-timers calendars.”
“Short-timers” were GIs nearing an end of their
Vietnam tour. The intricately designed calen-
dars contained spaces for 365 days and they were
openly displayed and cherished as “short time”
approached. “Short-timers” were revered by
their peers, and almost daily led their peers
through fantasy ritual descriptions about how
carefree life would be upon returning home.
For the GJ who was struggling with psycho-
logical breakdown due to the stresses of combat,
the DEROS fantasy served as a major prophy-
lactic to actual overt symptoms of acute combat
reaction. The vast majority did hold on as evi-
denced by low psychiatric casualty rates during
the war (President’s Commission on Mental
Health, 1978).
Struggle to Hold on Difficult
The struggle to hold on was difficult for most.
Motivations that keep combatants fighting, unit
esprit de corps, small group solidarity and an
ideologic belief that this was the good and just
fight were not present in Vietnam. Complete
strangers, often GIs who were strangers to the
speciality of the individual unit, were rotated
in as others rotated out. Veterans who had
reached a level of proficiency also had reached
their DEROS date and were rotated. Green
troops or “F.N.G.’s” ( new guys) with
poorly developed skills took their places. “New
guys” were avoided by seasoned troops until they
had a couple of months of experience because
no short-timer wanted to get killed by relying
on an inexperienced “F.N.G.” It is obvious that
endless arrivals and departures slashed unit
culture and esprit.
It was a rare occurrence that Vietnam veterans
wrote to their buddies still in the country
(Howard, 1976). Survivors’ feelings of guilt
about leaving buddies behind to an unknown fate
precluded the need to keep in touch (Goodwin,
1980 ) . It is even rarer to see two or more getting
together after the war. Contrast this to the con-
tinual reunions of World War II veterans.
Another unique factor of Vietnam was its
guerrilla nature. In World War II, the U.S. was
confronted by a uniformed, easily recognizable,
foe. A focus of rage was therefore available to
the World War II combatant. Vietnam was quite
the opposite. The enemy was rarely uniformed.
American troops were often forced to kill women
and children combatants. There were no real
geographic lines of demarcation. All land was
contested and the entire country seemed hostile
to the Americans. Surprise-firing booby traps
became the unseen, most feared enemy tactic,
in which the enemy himself was rarely sighted.
The war to the combatant became an endless
line of casualties and rotations with no land won
or lost and a poorly identifiable foe. Rather than
an ideologically justifiable experience, the war
became a private war of survival to each
American. Rage created by these situations was
widespread among troops. It showed itself as
violence and mistrust toward Vietnamese, toward
authorities, and finally toward the society that
had sent these troops and then failed to support
them.
This also was America's first teenage war
(Williams, 1979). The average age of the Viet-
nam combatant was 19.2 years while the average
of World War II combatant was 26.4 years
(Wilson, 1979). Developmental models point to
this period for most adolescents involving
psychosocial moratorium (Erikson, 1968) dur-
ing which the individual takes time to build this
enduring concept of self. This important step —
identity vs. role confusion — was clearly disrupted
“The suicide rate is startling. A sober-
ing fact is that by 1979 more Vietnam
veterans had died by their oivn hand
since the tear than actually died in com-
bat.”
for the adolescent, combatants via ambiguous
roles and conflicting values associated with com-
bat. This led to many subsequent problems. The
early twenties becomes the time for resolving the
conflict of “intimacy vs. isolation” (Erikson,
1968). Without resolution of “identity vs. role
confusion,” the individual is decidedly handi-
capped in resolving “intimacy vs. isolation.”
Vietnam was the first war where tranquilizers
and phenothiazines were therapeutically ad-
ministered to combatants (Jones & Johnson,
1975). This allowed many who might have be-
come acute combat reaction (shell shock)
victims of earlier wars to continue to function
until their DEROS date arrived.
Self-Medication Routine
Self-medication via cannibis or opiates was
routine. The military viewpoint of opiate abuse
was that the behavior was problematic, and
opiates users were discharged administratively
with diagnoses of character disorders (Kormos,
1978). Interestingly, cannibis users did not
seem to contribute to a lack of readiness or an
increase in psychiatric problems. Quite to the
194
The West Virginia Medical Journal
contrary, cannibis seemed to serve a medicinal
purpose and work as a buffer in submerging and
delaying symptoms of acute combat reaction
(Horowitz and Solomon, 1975).
Finally, when the Vietnam veteran did get
home, his DEROS fantasy was quickly replaced
by harsh reality. The civilian population of
World War II had been exposed to movies about
the struggle of readjustment by veterans; witness
“The Man in The Grey Flannel Suit;” “The
Pride of the Marines,” and “The Best Years of
Our Lives.” These movies gave the civilian
population a context in which to consider the
returning veteran (DeFazio, 1978). On the
other hand, the civilian population of the Viet-
nam era had been relentlessly exposed via tele-
vision’s six o'clock news to the horrors of war.
They were angry, tired a,nd numb. America was
not ready psychologically or socially to welcome
home Vietnam veterans.
Returning Vietnam veterans found a confused,
divided country. They had not returned victors
in any struggle — military, ideologic, psychologic
or social. Their world had indeed changed, and
they also had been changed.
What they experienced in Vietnam and upon
return will leave a mark that they may never
erase. To this author, one veteran summed it up
when he said, “I will go on and try to enjoy
life again, but I will never be young again . . .
they stole my youth.”
Where Were Vietnam Veterans in 1981?
In a discussion of the purpose of the paper
with a physican who heads the emergency room
very near the West Virginia Veterans Admini-
stration Center in Huntington, he expressed
doubt that problem-ridden veterans often are
seen in that facility. His comment was, “We
don't see many Vietnam veterans with emotional
problems.’ This remark has allowed the authors
to understand that he (and certainly others)
are oversimplifying a huge and complex public
health problem that goes far beyond “emotional
problems.” Manifestations of PTSD are diffuse
and, taken out of context, often are unrecognized
as a part of the syndrome.
To assist practitioners in gathering pertinent
information from their patients, it is necessary
to give some insight into the type of lives that
these veterans were leading in 1981. Unemploy-
ment had become a major problem for these
veterans. Many felt betrayed in that draft
resisters and nonveterans in their age group
were able to continue non-interrupted career and
educational tracks. Black and socioeconomically
disadvantaged veterans have less effective peer
support and, as such, have been especially vulner-
able to unemployment’s special stresses. The
temptation is to contend that these individuals,
regardless of military experience, would occupy
the same rung on the career ladder. However,
when background and educational differences
are controlled statistically, veterans still show
residual disadvantage in education and occupa-
tional attainment (Rothbart & Sloan, 1981).
Vietnam-era veterans as well as Vietnam combat
veterans exhibit this phenomenon although the
disadvantages are especially pronounced in com-
bat veterans. When Vietnam-era and combat
veterans are compared to their non-veteran peers,
the striking conclusion has to be that military
duty in Vietnam bad a negative effect on post-
military achievements ( Rothbart & Sloan,
1981).
Now that most Vietnam veterans are in the
age group of 30-38 years, it should be noted that
future attainment of occupational goals probably
has been irrevocably handicapped (Rothbart &
Sloan, 1981).
Concerning the social and psychological prob-
lems of this group, it has become apparent that
these men and women are especially troubled by
problems of alienation, psychiatric symptoms,
medical problems, drug and alcohol use and
trouble with the law. Further, it should be under-
stood that the Veterans Administration as the
traditional provider of services to veterans has
been utilized by only a small minority of veterans
with medical problems. In fact, only about 37
per cent of Vietnam veterans with residual
physical problems utilize the VA. These findings
have been noted by at least two major studies
including the 1970 National Survey of VA Util-
ization, and Lauffer. Frey-Wouter, Yager, 1981.
Depression a Common Problem
Depression is a common problem of combat
veterans. Classic symptoms as described in the
DSM III are the rule: sleep disturbances,
psychomotor retardation, feelings of worthless-
ness, inability to concentrate and suicidal
thoughts plague this group (Williams, 1979).
Currently, black combat veterans, in fact, report
stress symptoms at a rate of 70 per cent while
white veterans report the symptoms at about a
33-per cent rate (Lauffer, Frey-Wouter, Yager,
1981 ). The suicide rate is startling. A sobering
fact is that by 1979 more Vietnam veterans had
died by their own hand since the war than
actually died in combat (Williams, 1979).
i
September, 1983, Vol. 79, No. 9
195
Isolation is a defense adopted by many
veterans of the Vietnam War. Combat veterans
have few friends. Many veterans have been able
to isolate themselves by repeatedly moving from
one geographic location to another, imposing an
immense stress on their families in the process.
It is not rare to find combat veterans who have
not had social contact with women for years.
Even those that are married impose rigid isola-
tion on their wives and children. Ineffective
resolution of “intimacy vs. isolation” (Erikson,
1968) due to having to rely only on one’s self
to survive the combat situation, as well as the
readjustment to civilian life in a society appear-
ing apathetic, if not openly hostile, has rein-
forced this attitude that the veteran can trust only
himself in life. Veterans have actually taken
weapons and attempted to live off the land in
isolated areas of the Rocky Mountains (Williams,
1979 ). Lynda Vandevanter of Vietnam Veterans
of America reported that upon the opening of
the Anchorage, Alaska, Veterans Outreach
Center, several Vietnam veterans appeared who
claimed to have lived for years in Alaska’s
wilderness as hermits.
Rage is a problem plaguing these men and
their contacts. Many have been known to strike
out violently at those around them, including
wives and children. These frightening episodes
lead many veterans to question their own sanity
around this issue. The antennae of the careful
diagnostician should raise there. Child or spouse-
abuse problems s 
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